What are the considerations for a young male with recently diagnosed thyroid cancer?

From the Guidelines

A young male with recently diagnosed thyroid cancer should undergo total or near-total thyroidectomy as the initial treatment, followed by radioactive iodine therapy (RAI) with I-131, to minimize the risk of recurrence and mortality. The initial treatment approach is crucial in managing thyroid cancer, and according to the ESMO clinical practice guidelines for diagnosis, treatment, and follow-up 1, total or near-total thyroidectomy is recommended whenever the diagnosis is made before surgery and the nodule is ≥1 cm, or regardless of the size and histology if there is metastatic, multifocal, or familial DTC.

Key Considerations

• The benefit of prophylactic central node dissection in the absence of evidence of nodal disease is controversial, but it may permit accurate staging of the disease that may guide subsequent treatment and follow-up 1.
• Compartment-oriented microdissection of lymph nodes should be performed in cases of preoperatively suspected and/or intraoperatively proven lymph node metastases.
• Surgery is usually followed by the administration of 131I activities aimed at ablating any remnant thyroid tissue and potential microscopic residual tumor, which decreases the risk of locoregional recurrence and facilitates long-term surveillance.
• Radioiodine ablation is recommended for all patients except those at very low risk, and the method of choice for preparation is based on the administration of recombinant human TSH (rhTSH) while the patient is on levo-thyroxine (LT4) therapy 1.

Long-term Management

• Lifelong thyroid hormone replacement with levothyroxine is essential, with dose adjustments based on TSH levels.
• For the first few years, TSH should be maintained at suppressive levels (below 0.1 mIU/L) to prevent recurrence, with regular monitoring every 3-6 months.
• Follow-up should include periodic neck ultrasounds, thyroglobulin level measurements, and whole-body scans as recommended by the endocrinologist.
• Young males should also consider sperm banking before RAI therapy due to potential temporary fertility effects, and should maintain a low-iodine diet for 1-2 weeks before RAI treatment.

From the Research

Considerations for Young Male with Recently Diagnosed Thyroid Cancer

• The incidence of thyroid cancer in young adults is rising, with differentiated carcinoma and medullary thyroid carcinoma being the two most common subtypes 2.
• Ultrasound-guided fine needle aspiration is the best initial test for evaluating a nodule or mass suspicious for malignancy 2.
• Tumor histology, radiographic findings, and clinical presentation guide surgical management, the need for adjuvant therapies, and the optimal approach to long-term follow-up 2.
• Radioactive iodine is used to reduce recurrence and improve survival for differentiated thyroid carcinomas, but its use is selective and based on the risk of recurrence and mortality 3, 4, 5.

Treatment and Follow-Up

• The initial management of differentiated thyroid cancer is surgical treatment followed by radioactive iodine therapy, which may include remnant ablation, adjuvant treatment, or treatment of metastatic disease 3.
• The use of low-activity radioactive iodine therapy may lead to early disease recurrence in patients with nodal metastases and extrathyroidal extension 4.
• Long-term treatment includes thyroid-stimulating hormone suppression and surveillance with serum thyroglobulin and radiologic assessment for nodal recurrence 5.
• Targeted therapy with tyrosine kinase inhibitors represents an important therapeutic option for the treatment of advanced cases of radioiodine refractory differentiated thyroid cancer, medullary thyroid cancer, and possibly for cases of poorly differentiated and anaplastic thyroid cancer 6.

Prognosis and Outcomes

• The prognosis for the most common thyroid malignancy, papillary thyroid carcinoma, is excellent 2.
• Patients with neither lymph node metastases nor extrathyroidal extension have excellent outcomes, regardless of initial ablative activity, with less than 10% of patients recurring over a 10-year time span 4.
• Recurrent disease in differentiated thyroid carcinoma is more common in patients treated with low-activity radioactive iodine in patients with lymph node metastases and extrathyroidal extension 4.