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Division of Endocrinology (E.L.M.), Shands Hospital, Gainesville, Florida 32610; Endocrine Service, Department of Medicine (R.J.R.), Memorial Sloan-Kettering Cancer Center, New York, New York 10021; Department of Medicine (C.A.S.), University of Southern California, Los Angeles, California 90033; Section of Endocrinology, Diabetes, and Nutrition (L.E.B.), Boston Medical Center, Boston, Massachusetts 02118; Division of Endocrinology (F.P.), University of Siena, 53100 Siena, Italy; Department of Medicine (L.W.), Washington Hospital Center, Washington, D.C. 20010; Division of Endocrinology (B.R.H.), University of Colorado Health Sciences Center, Denver, Colorado 80262; Department of Endocrine Neoplasia and Hormonal Disorders (S.I.S.), University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030; Division of Endocrinology (D.S.C.), Sinai Hospital, Baltimore, Maryland 21215; Department of Medicine (G.D.B.), Cedars Sinai Medical Center, Los Angeles, California 90048; Section of Endocrinology, Diabetes, and Nutrition (S.L.), Boston Medical Center, Boston, Massachusetts 02118; Division of Endocrinology and Metabolism (T.F.D.), Mount Sinai Medical Center, New York, New York 10029-6574; Division of Clinical and Molecular Endocrinology (B.M.A.), University Hospitals of Cleveland, Cleveland, Ohio 44106; Division of Endocrinology (P.W.L.), Johns Hopkins Hospital, Baltimore, Maryland 21278; and Division of Endocrinology (A.P.), University of Pisa, 56124 Pisa, Italy
Address all correspondence and requests for reprints to: Dr. Ernest L. Mazzaferri, 4020 SW 93rd Drive, Gainesville, Florida 32608-4653. E-mail: mazz01{at}bellsouth.net.
Recent studies have provided new information regarding the optimal surveillance protocols for low-risk patients with differentiated thyroid cancer (DTC). This article summarizes the main issues brought out in a consensus conference of thyroid cancer specialists who analyzed and discussed this new data.
There is growing recognition of the value of serum thyroglobulin (Tg) as part of routine surveillance. An undetectable serum Tg measured during thyroid hormone suppression of TSH (THST) is often misleading. Eight studies show that 21% of 784 patients who had no clinical evidence of tumor with baseline serum Tg levels usually below 1 µg/liter during THST had, in response to recombinant human TSH (rhTSH), a rise in serum Tg to more than 2 µg/liter. When this happened, 36% of the patients were found to have metastases (36% at distant sites) that were identified in 91% by an rhTSH-stimulated Tg above 2 µg/liter. Diagnostic whole body scanning, after either rhTSH or thyroid hormone withdrawal, identified only 19% of the cases of metastases. Ten studies comprising 1599 patients demonstrate that a TSH-stimulated Tg test using a Tg cutoff of 2 µg/liter (either after thyroid hormone withdrawal or 72 h after rhTSH) is sufficiently sensitive to be used as the principal test in the follow-up management of low-risk patients with DTC and that the routine use of diagnostic whole body scanning in follow-up should be discouraged. On the basis of the foregoing, we propose a surveillance guideline using TSH-stimulated Tg levels for patients who have undergone total or near-total thyroidectomy and 131I ablation for DTC and have no clinical evidence of residual tumor with a serum Tg below 1 µg/liter during THST.
The consensus meeting was supported by an unrestricted grant to the University of Florida by the Genzyme Corp. (Cambridge, MA).
Abbreviations: DTC, Differentiated thyroid carcinoma; DxWBS, diagnostic whole body scanning; IMA, immunometric assay; rhTSH, recombinant human TSH; RxWBS, posttherapy whole body scanning; Tg, thyroglobulin; TgAb, anti-Tg antibodies; THST, thyroid hormone suppression of TSH; THW, thyroid hormone withdrawal.
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