Nader, I guess it would depend on a few things

1. Papillary vs follicular - I guess in my experience the papillary cases do a little better

2. If papillary - is it classical or insular/tall cell i.e. worse pathology

3. If follicular - is it classical vs hurtle cell, again, hurtle cells perhaps do a little worse

Either way, it has metastasised but is still Iodine avid, which is good. Presumably the thyroglobulin is also raised (or TgAbs) and so we should expect some effect from ablation. 

I would think testing for BRAF may also raise the spectre of novel chemotherapy if the Tg persists or more mets turn up. 

We occasionally consider RT for unresectable and persistent disease if it has little iodine avidity. 

The only other thing of interest would be if it is peripheral enough, you could consider surgery for the met. Slightly unorthodox, but maybe worthwhile if persistent. 

Hopefully stays I131 avid and responds well to therapy, but I guess I would give the patient a fairly guarded prognosis, perhaps a 5yr survival of 70-80%. 

All the best

Bruce

Dear Nader

i suppose if the involvement of the left lung is due to direct invasion of tumor in thyroid to lung, so prognosis is much better than metastasis to the lung

second if the tumor and left lung lesion is operable or not?

if possible en-block resection of tumor can give a better survival.

Thank you very much for your reply. the nature of the lung lesion is not know yet. It is not clear whether this is a direct invasion and remnant of the thyroid tumor or hematogenic metastasis of the tumor. Tumor itself was T2 N1 before. and the patient has received 2 courses of 150 curie radioactive iodine after surgery.  among the better prognostic factors of this patient is younger age and uptake of the iodine by the met lesion.  . I would also try to test her for BRAF which may offer options as targeted treatment as Bruce mentions in his response.

Nader

I would like to add few points to that of Bruce;

The prognosis will be much better and survival will be >90% in 10 years if you have no opacity in CXR, the lesion uptake was decreased after radio-iodine therapy. Also the rate of Tg decrement is very important. After two dose of I-131, how was Tg response?  If lesion is visible on CXR and if it was single on postablation whole body iodine scan, you may go for surgical resection before the third dose, These factors are more important than BRAF mutation.