Category Archives: Research

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.

Trying to stay research-free

We are at the beach for an extra long weekend getaway, which means I am writing this on my phone.  I have been trying really hard to stay research-free, with mixed success. The past few days have been good, and I have made a personal vow to myself not to look up anything related to my thyroid issues at least while we are on vacation.

That said, I did go on a PubMed binge several days ago (before vacation), and I learned a few more things that I wanted to make note of here.

One is that “hemosiderin laden macrophages” can occur in HCC. (ETA: Here’s the article.).  So, in terms of my Hurthle cell lesion, it doesn’t, as I previously believed, matter if my macrophages have hemosiderin or not.

Also, I had previously read an abstract that listed “absence of inflammation” as an increased risk factor for malignancy in Hurthle cell lesions. I thought this was a food sign for me, since I know my thyroid has inflammatory cells (lymphocytes) in it. But I found the full text of the article, and what “absence of inflammation” meant in their study was an absence of inflammatory cells within the lesion. Well, as far as my FNA report goes, there aren’t any inflammatory cells in my Hurthle cell lesion, so that is no longer a factor in my favor.

I feel like these two findings tip the needle a little away from the benign side, but not necessarily more towards the malignant side, if that is even possible or makes sense. I’m not sure it does.

The fact is that I feel mostly like I will have the surgery, get a benign diagnosis (maybe including Hashimoto’s and/or multi-modular goiter) and go on my merry way. I know that things may go a different direction, and I am trying to be prepared for that possibility without dwelling on it or inviting it into my life.

Weaning is still not going great. We are going to try to use the change of routine during this vacation to eliminate nap-time nursing.  Then we’ll be down to just first thing in the morning.

Later.

Macrophages

Ok, so I couldn’t leave well enough alone.  I HAD to keep on researching.

Let me back up.  Here is the word-for-word write up of FNA of the the larger nodule on the isthmus of my thyroid:

Hurthle cell lesion–see comment

COMMENT:

The specimen consists of numerous Hurthle cells and fragments of Hurthle cell epithelium, with a population of macrophages.  The differential diagnosis includes Hurthle cell change in a background of thyroiditis or a hyperplastic colloid nodule versus a Hurthle cell neoplasm.  Clinical correlation recommended and follow up as indicated.

So that actually didn’t sound too bad, especially the idea that it could be “Hurthle cell change in a background of thyroiditis.”

But I couldn’t leave well enough alone.  I wanted to know what, if any, meaning the macrophages had.  I had some vague memory that macrophages were immune cells, maybe a type of white blood cell?  I knew that certain cell types like lymphocytes tended to point towards a benign nodule.  So I went looking, using “macrophage” as a term in combination with “Hurthle cell lesion,” “Hurthle cell adenoma,” “Hurthle cell FNA,” etc. ad nauseum.

I found one case study in which two different patients had similar FNA samples that included Hurthle Cells and macrophages.  One ended up being a Hurthle Cell Adenoma (benign) and the other a Hurthle Cell Carcinoma (malignant).  So I know that macrophages could be present in either.

Then, for whatever reason, I searched for “macrophage thyroid cancer.”  From that I learned that macrophages are generally present in tumors (benign or malignant) and that a certain type of macrophage, known as a Tumor-Associated-Macrophages can sometimes make up up to 50% of a tumor, and that their actions tends to help the tumor grow and spread.

I found this article.  The title alone almost sent me into a panic attack.

I had a little freak out moment, feeling SURE that the “population of macrophages” meant my nodule is FOR SURE cancer. I have reeled it in a bit, and I’m now back to the recognition that “tumor-associated” doesn’t have to mean “cancer-associated,” and that, once again, I cannot find out if my nodule is cancer or not by doing research.  Still, I am not comforted.

I’ve also learned that “hemosiderin-laden” macrophages are usually associated with benign tumors; they “digest” red blood cells when a colloid nodule (always or almost always benign, from what I understand) undergoes “hemorrhagic decay”.  My FNA report didn’t say whether the macrophages were “hemosiderin-laden” or not.  So I really have no idea where I stand.

Before I made my macrophage discovery, I sent Dr. B an email to ask how long surgery should take (45 minutes to an hour)  and where pathology would be done (right here in our local hospital).  I have now looked up the pathologists on staff and am considering sending them gift baskets the day before my surgery, to make sure they do top-notch work for me.

Also, my sweet, sweet Aunt Sharon has said that if I need her, she can come for a few days.  We are going to play it by ear to see how things go.  And UK is in Uganda, preaching.  Love it.

Ok, I REALLY, REALLY need to forget all about this until maybe a few days before June 7th!  Although, I think it would be good to work on some things that would be helpful to accomplish before surgery. I am going to put my “folder” (containing my lab reports, surgery instructions, etc.)  somewhere out-of-the-way.

Should I Google “Hashimoto’s macrophage,” just to make myself feel better?  You see how sick I am?

ETA:  I did Google some more.  I am back to the realization–full realization, not just what I’m telling myself to think–that macrophages don’t mean I have cancer, and very well could point to a Hurthle Cell Lesion associated with Hashimoto’s.    Must.  Stop.  Googling.

Surgery Scheduled

Rusty went with me to my follow-up appointment with Dr. B on Tuesday.

Dr. B is going to take out the right side of my thyroid on June 7th. That’s a FRIDAY! Which means that Rusty might only have to take off the day of surgery, and maybe no one will have to come and help me.

My friend, A, has been telling me how easy her surgery was (she had the same surgery I am scheduled for), how little pain she had, and how quickly she was able to do her normal activities. Praying for a similar experience.

Dr. B does the “minimally invasive” version of the surgery, which should mean a smaller scar. They will also do initial pathology while I am in surgery, with full pathology completed afterwards. What this means is, there is a possibility they could catch a cancer before they close me up, enabling them to do a complete thyroidectomy without a second surgery. What I have read is that this pathology procedure catches about half of the cancers. The other half would have to come back for a second operation.

I was pleased that Dr. B didn’t think I needed the left lobe out at this point. He said that it looks “almost” normal. I just REALLY don’t want to be thyroid-free if it isn’t necessary.

He said that he didn’t think I will need an endocrinologist going forward, but if he thinks I am going to go around with less than half a thyroid in my neck and NOT see an endo, he has another think coming. :) I talked to S at Bible study last night, and she likes her endo a lot. She suggested I might want to see an endo before having half my thyroid out, but I’m pretty sure that no matter who I see, this is the path in front of me.

Ok, so I feel like we are doing the right thing–taking the best next step.

However, is it ok to say that I am still a little disappointed in my care? Here’s the part where I get whiny. If you would like to skip the rest of this entry, I promise I won’t get my feelings hurt. :)

Whine #1–The pathologist who looked at my FNA samples only made two slides per sample. At some labs, six slides is considered a minimum. Maybe that won’t make a difference, but two just doesn’t seem very thorough.

Whine #2–When Dr. B sent my FNA samples off, he didn’t include ANY clinical history (i.e., sample is from a mixed solid/cystic nodule measuring 2.8x 1.3x 2.9 cm), which is supposed to help the pathologist make a more accurate assessment of what he or she is looking at.

Why I am not going to make a fuss about this: Both nodules are coming OUT in less than a month. So if they’re baddies, they’ll be gone and they can find out for sure after they are out. A Hurthle Cell Lesion has to come out anyway.

A couple more interesting factoids about Hurthle Cell Lesions:

I have read conflicting reports that their malignancy rate is somewhere between 13% and 35%. That’s a pretty big range. I am banking on being under 40, having a lump smaller than 4 cm, and having (possible) Hashimoto’s thyroiditis. (Dr. B says it can’t be diagnosed by biopsy–but that’s not what I’ve read. Yet another reason to go see an Endo. Dr. S, here I come! After all this surgery hullabaloo is over.)

Interestingly, lumps diagnosed as Hurthle Cell Lesions that turn out to be malignant often are not Hurthle Cell Carcinoma. They can be any of the other kinds of Thyroid cancer–Papillary, Follicular, etc.

Enough for now. I am going to try REALLY HARD to quit thinking about this whole thing until my surgery gets here.

Note to self:

You can read and re-read all the journal articles about what percentages of Hurthle Cell Lesions are cancerous and what percentage are not.  You can memorize all the factors that predict whether a HCL/N is cancerous or not.  But NONE OF THAT can tell you whether your particular lump is malignant or not.  Only surgery and a good pathologist can make that determination.  YOU ARE JUST GOING TO HAVE TO WAIT TO FIND OUT. STARING AT SCHOLARLY WRITE-UPS ON YOUR COMPUTER SCREEN IS JUST GOING TO GIVE YOU A CRICK.  SO GO TO BED ALREADY.