Follicular Thyroid Cancer

Intrathyroidal Spread

This does not tend to occur as frequently as in papillary cancer. Tumours tend to be isolated, encapsulated (90%) and unilateral. Total or near thyroidectomy is advocated to facilitate 13'I screening for metastatic disease and increase the efficacy of therapeutic 131I. An exception to total or near total thyroidectomy may be made in minimally invasive follicular where total thyroid lobectomy and isthmusectomy are regarded as sufficient surgical treatment.

Local Invasion

Extrathyroidal invasion in follicular thyroid cancer is present at initial procedure in about 25% of patients (45). As with papillary thyroid cancer local invasion into adjacent structures should be managed where technically feasible by primary en-bloc excision to include the affected organs. The RLN on the affected side may need to be sacrificed if it cannot be separated or shaved from the tumour mass. On rare occasions, follicular thyroid cancer may invade directly into the jugular vein. In this situation it may be necessary to open the vein and retrieve the metastatic tumour which may extend as far as the right atrium.

Nodal Metastases

Regional lymph node metastases are rare in follicular thyroid cancer, occurring in only 10% of patients and are associated with advanced primary disease. Cervical lymphadenopathy present at initial presentation should be managed by modified radical neck dissection, in company with total thyroidectomy. Recurrent regional metastases should likewise be treated by modified radical neck dissection. Reduction in tumour load will increase the effectiveness of therapy.

Distant Metastases

Haematogenous spread to lung, liver and bone is more common in follicular than papillary thyroid cancer. Approximately 10%-30% of patients have distant metastatic spread present at initial presentation (45). Distant metastases may be treated by:-

Radioiodine

The treatment rational for radioiodine in DTC has already been outlined above. Tumour differentiation probably has a significant role in control or ablation of recurrent disease as more differentiated tumours are likely to concentrate mI. Overall, follicular thyroid cancer tends to concentrate 13II better than papillary thyroid cancer. In contrast, Hürthle cell cancers as discussed above are an important exception.

Radiotherapy

As in papillary thyroid cancer, DXT may offer a role in the control of unresectable, residual primary tumour, locally recurrent disease, regional lymph node metastases and for the control of pain in bone metastases.

Chemotherapy

This treatment modality has little to offer in the management of metastatic follicular carcinoma ofthe thyroid.

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