Category Archives: Lymph Nodes

Follicular Variant Papillary Thyroid Carcinoma, Second Surgery Today

Just as I did when I had done research on Hurthle Cells way back when I was diagnosed with a Hurthle Cell Lesion and wanted to understand what that meant, I want to put down here some of what I have learned about the particular variety of cancer I was diagnosed with after my first surgery:  Follicular Variant Papillary Thyroid Carcinoma, FVPTC.

The very first things I read indicated that FVPTC pretty much behaves the same and is treated the same as “Classical” PTC (cPTC).  Since then I have read a good deal more, and have found that this is not always the case.  In both cPTC and FVPTC, it makes a difference if the tumor is encapsulated or diffuse (spread out with no clear margins in the tissue).  Just like you might think, diffuse tumors tend to spread more readily and are considered more “aggressive.”

There is also an “in between” type that is not encapsulated but is not diffuse–From what I have read, it tends to behave more like encapsulated tumors and is, as these authors love to say, more “indolent.” I haven’t found much about that, so cant say more.

Then there is a great deal of research published within the last two to three years that examines encapsulated FVPTC (EnFPTC) versus unencapsulated.   See this, this, and this.  The basic takeaways are two-fold.

One is that FVPTC tends to behave more like FTC (Follicular Thyroid Carcinoma) rather than PTC.  That means it is more likely to spread distantly through the blood than to reoccur locally in the neck (in lymph nodes, etc.)  It also means that a totally encapsulated FVPTC might even be considered benign.  In FTC, malignancy is determined by capsular or vascular invasion.

The other take-away is that encapsulated FVPTC is generally very non-aggressive.  It seldom spreads anywhere.  There is a good deal of debate about whether it warrants a total thyroidectomy if there is no vascular invasion.  Even with capsular invasion, some authors believe a total thyroidectomy is not worth doing.

Then there is an alternate point of view, that encapsulated FVPTC can have vascular invasion that is so microscopic as to be almost undetected, and that in such cases a tumor that looks to be harmless could end up with distant metastases years later.

So all of this was what I have waded through since my diagnosis, what I’ve struggled with as I decided whether to have the completion surgery or not. What it comes down to is that I do not believe completion surgery will change my prognosis, but it will lower my risk of recurrence and make it easier to be monitored going down the road. I put my trust in my God to continue with me down this path, wherever it leads me.

And in a few minutes, I’ll be headed over to the hospital for my surgery.  Last time I was anxious about having surgery–since I’d never really done that–and about what they would find.  This time I know what to expect and the procedure doesn’t worry me.  I don’t really expect them to find any more cancer, but know it is a possibility.  This time, I am more concerned about adjusting to life without a thyroid, life on a daily med.  Again I put my trust in the Father to take me forward one step at a time.

See you on the flip side.

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Water Under the Bridge

VBS and Rustic Youth Camp are done.

VBS went very well, I think.  I ended up not doing quite all that I planned, but that was ok, and a good lesson to learn in not biting off more than I can chew.  Usually, if I don’t end up achieving all that I hoped to on a project, I blame myself for not working harder.  Maybe, finally, I am coming to realize that some of the problem is that I tend to have grand ideas–bigger than I am able to pull off sometimes.  This season in my life is teaching me that I don’t have to do amazing and spectacular things to be effective.

Camp was wonderful.  It was so much fun to have Sarah and the kids there.  It was a blessing to see so many good friends and to make new ones, too.  I need to work on the way I interact with children, including mine.  I have a tendency to be more stern than I need to be–to jump to sternness instead of letting gentleness be my trademark.  I don’t think I did a bad job as a teacher, but I could have done better.  Always more to learn.

To review my last post, I was anxious because I wanted to have an ultrasound done on my neck to look for suspicious lymph nodes.  The American Thyroid Association and the National Comprehensive Cancer Network both recommend such an ultrasound prior to surgery for Papillary Thyroid Carcinoma (PTC) because it spreads to lymph nodes so frequently, and it’s better to get effected lymph nodes out in the first surgery if possible.

I was going to try to just accept that Dr. B hadn’t ordered it and it would be ok, but I couldn’t let it go, so I emailed him to ask him about it.  He said that he would be glad to do it, and I told him I would take him up on it.

Then I kept on reading–I wanted to learn more about the particular variant I was diagnosed with–Follicular Variant Papillary Thyroid Carcinoma (FVPTC) and even more specifically, encapsulated follicular variant (EnFVPTC).  What I learned was that EnFVPTC is much less likely than PTC to spread to lymph nodes. (More about that in my next post.)  So then I felt a little silly about requesting the ultrasound.  I decided that if they called and told me it was scheduled during camp week I would just cancel it rather than rescheduling.

And that’s what happened.  Dr. B’s nurse called and told me my ultrasound was set for July 3rd.  I told her that I would just cancel it, since I would be out of town. Then ADI–the place that actually does the ultrasounds–called to pre-register me.  I cancelled with them as well.  Then, while I was gone, ADI called the house REPEATEDLY to pre-register me, and Dr. B’s nurse called me again to tell me that my ultrasound was actually July 2nd, not the 3rd.  All this was kind of confusing to me, since I had told Dr. B’s nurse that I was cancelling the ultrasound, since it was at my request anyway.  I am sure that Dr. B is going to think I am a complete nut job before this is all over.  The only thing I know to do is to be as sweet as possible to them.

Also behind me is another crisis on this journey. I had to decide whether or not to have this surgery done.  I’ve already outlined my anxieties about it.  For a few days, I was seriously considering calling it off.  Ultimately, I decided that I would do it.

The main reason for me to not have the surgery was fear of an apocalyptic future event that would leave me without medicine.  What I decided was that in such an event, my survival was unlikely anyway, and I couldn’t base my decision on speculation.  If I kept half of my thyroid, my chances of recurrence would be much higher.

I have also been anxious about adjusting to life without a thyroid–again, the message boards add fuel to the fire.  There are so  many over there who have struggled to adjust to life on thyroid replacement.

And the honest truth is that I know myself, and I am a person who likes to keep my options open.  I don’t like making irreversible decisions.

Anyway, my completion thyroidectomy is scheduled for Thursday, July 11th, three days from now. After all of that, I feel that it’s the best decision I could make for my circumstances.  I’m hoping all of these anxieties can just be water under the bridge as we move forward.

Message Boards and “The Big C”

I have been more emotional the past few days.  Not bad over all, but I have had a few moments when I could not hold back the tears.  Maybe it’s all part of the process of coming to grips with this thing.

I think it kind of started when I signed up on the ThyCa message boards over at Inspire.  Message boards can be very helpful–they give you a chance to talk to other people who are dealing with the same thing you are.  I remember when I had my second miscarriage, going on message boards and talking to other women who had gone through the same loss was helpful for me.  It’s good to be able to ask if your experience is normal (i.e., common to many), or what to expect, etc.

One of the problems with topic-specific message boards is that they are inherently unbalanced.  Occasionally people come on to share good news, but generally, people post when they are worried or upset.  It’s good that they have a “safe place” to go for reassurance, among people who understand.

But as a reader of message boards, you are exposed to a disproportionate number of negative experiences–In the case of thyroid cancer, to make a specific example, you hear a LOT about people who are facing metastasis, problems balancing their thyroid hormones, doctors who are uncooperative, family and friends who don’t understand what they’re going through, and so on.  In other words, it can be very easy to get the impression that for most people, the thyroid cancer journey is really rough.

So I was on the boards, and I read about several people having “lymph node mapping” prior to their surgery.  Basically, it’s a detailed ultrasound of your neck looking for suspicious lymph nodes prior to surgery so that you can have them out the first time around rather than having to go in for another surgery later.

I looked into it–I have not had a formal “lymph node mapping” done.  I know That Dr. B looked at my lymph nodes a little on ultrasound when he did my FNAs, And I know that he inspected my “central compartment” lymph nodes during my first surgery and didn’t see any that looked worrisome.

So I emailed him about it.  I am trying not to abuse my email privileges with Dr. B.  It’s so rare to find a doctor who INVITES you to email him with any questions you have.  I don’t want to make him regret the offer.

Basically, he said what I already knew about the inspection he had already done, and he added that he would take the lymph nodes in front of my trachea for sampling, which he said would be considered “more than adequate” in my case.

What he meant by “in this case” is that I had a very small carcinoma.  At 1.2 cm, it is barely large enough to call for the removal of the other lobe (>1 cm is the guideline), and is therefore considered, at least right now, to be low-risk.

And he said something else, which I already knew.  He said that “we know that we over-treat these small thyroid cancers most of the time.”  And this lead me to thinking again about how much I really don’t want to lose the rest of my thyroid.

So here’s the picture, people.  I am, on one side, almost in tears over having the rest of my thyroid out and being dependent on medication for the rest of my life (not to mention, thanks to the message boards, very concerned about how difficult the adjustment will be to life without a thyroid), and on the other hand, anxious beyond measure that my surgeon has not inspected my lateral lymph nodes for possible metastasis. (Which is what ThyCa, the NCCN, and the ATA all recommend–I’m not crazy for wanting this.)

[By the way, here’s a picture of the different lymph node regions of the neck, if you are wondering what on earth I’m talking about:

F1.medium

Dr. B was saying that he always thoroughly checks out the central compartment (VI), whereas guidelines recommend ultrasound inspection of regions II, III, and IV as well, from what I have read.]

Ok.  So let me sum up–I want to both ramp up AND scale back my treatment.  Which is IRRATIONAL, people.

So here’s my action plan.

  • “Unfollow” all the messages I’m currently following on the ThyCa message boards so that I don’t keep getting emails encouraging me to check in.
  • Generally, try to stay away from thyroid cancer boards, blogs, etc., at least for a while.  (Not necessarily including this one–I am finding it very useful to “talk” through my issues here.)
  • Pray that God will help me accept the loss of control (or at least the illusion of control) posed by having my thyroid gone.
  • Remind myself, repeatedly, of all the reasons why it’s better to have it out.
  • Let Dr. B do his thing–which I do believe he’s very good at–and not worry about the rest.

The best thing to come out of the message boards, for me, at least, was a comment by one of the posters who was trying to encourage someone with a new diagnosis.   She said,

“For me, I have had to learn that cancer is my little “c” and Christ, who I lean on when scared, is my big “C”!

So I am going to remember that Christ is the only “Big C” in my life.  And he can totally handle the “little c.”