e***y
发帖数: 4307 | 1 【 以下文字转载自 Medicine 讨论区 】
发信人: eeguy (ILYF), 信区: Medicine
标 题: 求助，老婆的甲状腺癌可能复发了
发信站: BBS 未名空间站 (Mon Sep 24 00:52:36 2012, 美东)
年初曾经发帖咨询过，当时的帖子在这里：http://www.mitbbs.com/article_t0/Medicine/31238469.html
老婆今年28岁，二月在UCSF确诊是papillary thyroid carcinoma，四月做了total
thyroidectomy，冷冻切片符合papillary，但是是diffuse sclerosing variant比较
aggressive，而且是moderately differentiated，所以当时已经知道复发的可能性很
大。七月份做了RAI，剂量是100 millicuries。RAI后的全身PET scan没有发现I-131
uptake，TSH在0.1左右，但是因为thyroglobulin antibody (TgAb)非常高（>3000），
所以thyroglobulin (Tg)指标虽然接近0，但是基本没有用。一直以来除了稍微缺钙其
他基本正常。
令我们非常意外的是，上周的颈部超声波发现一1.1x0.4cm的钙化结节，长在气管上，
另外还有一个1.3x0.6cm的带有microcalcification的淋巴结。RAI和PET scan才过了两
个月，怎么这么快就长了这么大的结节？请问这里的专家，应该采取何种治疗方案？我
看UCSF一直以来的做法都是standard procedure，但是她的情况是否属于比较恶性的，
需要更aggressive的治疗呢？是否可以进行第二次手术？另外，我很担心发生远端转移
，例如肺转移，似乎现在治疗手段不多阿。
最后再问一个问题，我们应该继续在UCSF看病吗？很多人说这是治甲状腺癌最好的，手
术似乎做的是不错，但是感觉到医生好像不紧不慢的，等手术和RAI都等好久。西部还
有什么好的医院吗？MD Anderson是不是比UCSF更好？ | z******1
发帖数: 666 | 2 Furhter surgery is definately necessary for your wife. | e***y
发帖数: 4307 | 3 Her TgAb levels have always remained extremely high above 3000, even one
month after total thyroidectomy. Could this mean that the surgery did not
completely remove the tumor? That really makes me doubt how good a job the
surgeon had done.
Also, at this point we are really not sure whether the RAI was effective.
What is a definite way to assess the RAI avidity?
Thanks a lot for your answers.
【在 z******1 的大作中提到】
: Furhter surgery is definately necessary for your wife.
| a*********d
发帖数: 2763 | 4 1. RAI后做的是whole body scan吧，你确定是PET?
2. 有的aggressive的肿瘤对I131不敏感，所以没有uptake
3. TgAb如果baseline就高，不说明问题，跟TG高是两回事情。
4. 淋巴结原来做手术前有吗？术前应该有详细的颈部超声，影响外科手术清扫淋巴的
范围。现在需要穿刺确诊。
5. 甲状腺癌的治疗手段很limited,如果I131不敏感，有复发，可以考虑参加clinical
trial, 现在有几个药可以试试看的。
6.甲状腺癌带瘤生存的情况很多，有时候就是没有办法根治的。
年初曾经发帖咨询过，当时的帖子在这里：http://www.mitbbs.com/article_t0/Medicine/31238469.html
老婆今年28岁，二月在UCSF确诊是papillary thyroid carcinoma，四月做了total
thyroidectomy，冷冻切片符合papillary，但是是diffuse sclerosing variant比较
aggressive，而且是moderately differentiated，所以当时已经知道复发的可能性很
大。七月份做了RAI，剂量是100 millicuries。RAI后的全身PET scan没有发现I-131
uptake，TSH在0.1左右，但是因为thyroglobulin antibody (TgAb)非常高（>3000），
所以thyroglobulin (Tg)指标虽然接近0，但是基本没有用。一直以来除了稍微缺钙其
他基本正常。
令我们非常意外的是，上周的颈部超声波发现一1.1x0.4cm的钙化结节，长在气管上，
另外还有一个1.3x0.6cm的带有microcalcification的淋巴结。RAI和PET scan才过了两
个月，怎么这么快就长了这么大的结节？请问这里的专家，应该采取何种治疗方案？我
看UCSF一直以来的做法都是standard procedure，但是她的情况是否属于比较恶性的，
需要更aggressive的治疗呢？是否可以进行第二次手术？另外，我很担心发生远端转移
，例如肺转移，似乎现在治疗手段不多阿。
最后再问一个问题，我们应该继续在UCSF看病吗？很多人说这是治甲状腺癌最好的，手
术似乎做的是不错，但是感觉到医生好像不紧不慢的，等手术和RAI都等好久。西部还
有什么好的医院吗？MD Anderson是不是比UCSF更好？
【在 e***y 的大作中提到】
: Her TgAb levels have always remained extremely high above 3000, even one
: month after total thyroidectomy. Could this mean that the surgery did not
: completely remove the tumor? That really makes me doubt how good a job the
: surgeon had done.
: Also, at this point we are really not sure whether the RAI was effective.
: What is a definite way to assess the RAI avidity?
: Thanks a lot for your answers.
| e***y
发帖数: 4307 | 5 谢谢回复
重新看了报告，是SPECT/CT，不是PET。貌似SPECT的resolution并不高，也许看不到小
的病灶
关于TgAb，由于非常高所以无法用Tg test来检查是否复发，是不是只有靠scan和
ultrasound来追踪了？如果甲状腺组织完全被切除或杀死，TgAb是不是应该降下来？
手术前有发现淋巴结肿大，术中取出23个，15个positive。不知道现在发现的淋巴结是
新的还是原来的。可惜手术后没有做过ultrasound，没有一个可以比较的baseline。问
题比较大的可能还是气管上的结节。如果是RAI后长的，有点吓人。希望能趁它还没有
长很大能再做一次手术。
您能举出几个可能有用的正在进行clinical trial的药吗？
我们住在湾区，一直在UCSF看，但是觉得医生对治疗不是很积极。手术后过了3个月才
给做RAI，一般都是4周就做的。是不是应该考虑去MD Anderson也看看？
再次谢谢您的信息。
clinical
【在 a*********d 的大作中提到】
: 1. RAI后做的是whole body scan吧，你确定是PET?
: 2. 有的aggressive的肿瘤对I131不敏感，所以没有uptake
: 3. TgAb如果baseline就高，不说明问题，跟TG高是两回事情。
: 4. 淋巴结原来做手术前有吗？术前应该有详细的颈部超声，影响外科手术清扫淋巴的
: 范围。现在需要穿刺确诊。
: 5. 甲状腺癌的治疗手段很limited,如果I131不敏感，有复发，可以考虑参加clinical
: trial, 现在有几个药可以试试看的。
: 6.甲状腺癌带瘤生存的情况很多，有时候就是没有办法根治的。
:
: 年初曾经发帖咨询过，当时的帖子在这里：http://www.mitbbs.com/article_t0/Medicine/31238469.html
| s*****e
发帖数: 404 | 6 Based on the pathology and 15/23 positive lymph nodes, it is likely an
aggressive tumor. I agree with againstwind, your wife needs biopsy of the
enlarged lymph node. She can get a PET/CT before biopsy to see whether the
lymph nodes have FDG uptake. Should these tests confirm recurrent disease,
it suggests that the tumor is radio-I insensitive. If PET/CT only shows
localized disease in the neck, surgery need to be considered. If she has
metastatic disease, she needs to be referred to medical oncology and start
treatment right away. clinical trials are preferred in this situation. The
cancer center of UCSF is not bad at all (rank #12 in cancer), they may have
clinical trials open. The NCCN recommends to clinical trials or consider
targeted therapy for metastatic radio-I insensitive thyroid cancer, because
traditional chemotherapy is not effective. Small inhibitors have be used in
metastatic thyroid cancers which are radio-I insensitive include sorafinib,
sunitinib, pazopinib. A phase II data on vandetanib was just published this
month.
I think you should call your wife's radiation oncologist and discuss your
concerns ASAP. Referral to other cancer center is an option, but it takes
time. While your wife is waiting for referral, she should get tests cooking.
We can certainly give your suggestions, but we are not your wife's
physician. Some of us may finish training, some are still in training, like
me. Some people who give suggestion may not be in medical field at all. | e***y
发帖数: 4307 | 7 Big thanks to you stareee for your detailed response.
Regarding the clinical trials, are the new drugs effective? I was reading
something about Nexavar yesterday and it seemed to have a lot of side
effects. But we're willing to try as long as it gives us some hope.
We also heard from multiple resources that UCSF has a good reputation in
thyroid cancer, which is why we went there in the first place and it's close
to home. So far our experience has been mixed. I trust that the surgeon
has a lot of experience and did a great job in the surgery. However, what
has been really frustrating for us is that the doctors and staff there lack
a sense of urgency and concern for my wife's situation. We all know her
cancer is aggressive and needs to be treated aggressively, but we haven't
seen any of that. Sorry about the rants...
have
【在 s*****e 的大作中提到】
: Based on the pathology and 15/23 positive lymph nodes, it is likely an
: aggressive tumor. I agree with againstwind, your wife needs biopsy of the
: enlarged lymph node. She can get a PET/CT before biopsy to see whether the
: lymph nodes have FDG uptake. Should these tests confirm recurrent disease,
: it suggests that the tumor is radio-I insensitive. If PET/CT only shows
: localized disease in the neck, surgery need to be considered. If she has
: metastatic disease, she needs to be referred to medical oncology and start
: treatment right away. clinical trials are preferred in this situation. The
: cancer center of UCSF is not bad at all (rank #12 in cancer), they may have
: clinical trials open. The NCCN recommends to clinical trials or consider
| s*****e
发帖数: 404 | 8 Targeted therapy in general only results partial response or stablize the
disease. Most of the data are from phase II. I am not sure whether there is
any phase III data published. There is no data on head to head comparison
among these inhibitors.
There is no free lunch. Any drug has side effects. Not everyone experience
all the possible side effects. If your wife were treated with some inhibitor
, and experience severe side effect, the dose could be reduced or switched
to another one.
I understand your frustration. But if your wife goes to MDACC for a second
opinion, it is going to be difficult for her to stay there for the whole
treatment. What we usually see in the clinic is that those patients still
follow up with a local oncologist. Most doctors do care about their patients
. One thing to keep in mind is that if you are unhappy with your doctor, let
him know but in a way that he can accept. He may have reasons that you do
not know.
Bless and good luck! |
|
