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Thyroid Cancer
Table of Contents
- General Information
-
- Celluar Classification
-
- Stage Information
-
Stage I papillary
Stage II papillar
Stage III papillary Stage IV papillary
Stage I follicular
Stage II follicular
Stage III follicular
Stage IV follicular
Medullary
Anaplastic
- Treatment Option Overview
Carcinoma of the thyroid gland is an uncommon cancer but, nonetheless, is the most
common malignancy of the endocrine system. Differentiated tumors (papillary or follicular)
are highly treatable and usually curable. Poorly differentiated cancers (medullary or
anaplastic) are much less common, are aggressive, metastasize early, and have a much
poorer prognosis. Thyroid cancer affects women more commonly than men, and the majority of
cases occur in patients between the ages of 25 and 65. The incidence of this malignancy
has been increasing over the last decade. The prognosis for differentiated carcinoma is
better for patients under the age of 40 without extracapsular extension or vascular
invasion.[1-5] Age appears to be the
single most important prognostic factor.[3] Thyroid cancer
commonly presents as a cold nodule. The overall incidence of cancer in a cold nodule is
12%-15%, but it is higher in patients under 40 years of age.[6]
The prognostic significance of lymph node status is controversial. One retrospective
surgical series of 931 previously untreated patients with differentiated thyroid cancer
found that female gender, multifocality, and regional node involvement are favorable
prognostic factors.[7] Adverse factors included age over 45 years,
follicular histology, primary greater than 4 cm (T2-3), extrathyroid extension (T4), and
distant metastases.[7,8] Other studies,
however, have shown that regional lymph node involvement had no effect [9] or even an adverse effect on survival.[4,5,10] An elevated serum thyroglobulin level
correlates strongly with recurrent tumor when found in patients with differentiated
thyroid cancer during postoperative evaluations.[11,12] Expression of the tumor suppressor gene p53 has also been
associated with an adverse prognosis for patients with thyroid cancer.[13]
Patients with a history of radiation administered in infancy and childhood for benign
conditions of the head and neck, such as enlarged thymus, acne, or tonsillar or adenoidal
enlargement have an increased risk of cancer as well as other abnormalities of the thyroid
gland. In this group of patients, malignancies of the thyroid gland first appear beginning
as early as 5 years following radiation and may appear 20 or more years later.[14] The thyroid gland may occasionally be the site of other primary
tumors, including sarcomas, lymphomas, epidermoid carcinomas, and teratoma, and may be the
site of metastasis from other cancers, particularly of the lung, breast, and kidney.
References:
- Grant CS, Hay ID, Gough IR, et al.: Local recurrence in papillary thyroid
carcinoma: Is extent of surgical resection important? Surgery 104(6): 954-962, 1988.
- Cady B, Rossi R: An expanded view of risk-group definition in
differentiated thyroid carcinoma. Surgery 104(6): 947-953, 1988.
- Mazzaferri EL: Treating differentiated thyroid carcinoma: where do we
draw the line? Mayo Clinic Proceedings 66(1): 105-111, 1991.
- Staunton MD: Thyroid cancer: a multivariate analysis on influence of
treatment on long-term survival. European Journal of Surgical Oncology 20: 613-621, 1994.
- Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. American Journal of Medicine
97: 418-428, 1994.
- Tennvall J, Biorklund A, Moller T, et al.: Is the EORTC prognostic
index of thyroid cancer valid in differentiated thyroid carcinoma?: retrospective
multivariate analysis of differentiated thyroid carcinoma with long follow-up. Cancer
57(7): 1405-1414, 1986.
- Shah JP, Loree TR, Dharker D, et al.: Prognostic factors in
differentiated carcinoma of the thyroid gland. American Journal of Surgery 164(6):
658-661, 1992.
- Andersen PE, Kinsella J, Loree TR, et al.: Differentiated carcinoma of
the thyroid with extrathyroidal extension. American Journal of Surgery 170(5): 467-470,
1995.
- Coburn MC, Wanebo HJ: Prognostic factors and management considerations
in patients with cervical metastases of thyroid cancer. American Journal of Surgery
164(6): 671-676, 1992.
- Sellers M, Beenken S, Blankenship A, et al.: Prognostic significance
of cervical lymph node metastases in differentiated thyroid cancer. American Journal of
Surgery 164(6): 578-581, 1992.
- van Herle AJ, Brown DG: Thyroglobulin in benign and malignant thyroid
disease. In: Falk SA: Thyroid disease: endocrinology, surgery, nuclear medicine, and
radiotherapy. New York: Raven Press, 1990, pp 473-484.
- Ruiz-Garcia J, Ruiz de Almodovar JM, Olea N, et al.: Thyroglobulin
level as a predictive factor of tumoral recurrence in differentiated thyroid cancer.
Journal of Nuclear Medicine 32(3): 395-398, 1991.
- Godballe C, Asschenfeldt P, Jorgensen KE, et al.: Prognostic factors
in papillary and follicular thyroid carcinomas: p53 expression is a significant indicator
of prognosis. Laryngoscope 108(2): 243-249, 1998.
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT,
Hellman S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
Cell type is an important determinant of prognosis in thyroid cancer. There are four
main varieties of thyroid cancer (although, for clinical management of the patient,
thyroid cancer is generally divided into well-differentiated or poorly differentiated): [1]
- a) papillary carcinoma papillary/follicular carcinoma
b) follicular carcinoma Hurthle cell carcinoma
c) medullary carcinoma
d) anaplastic carcinoma small cell carcinoma giant cell carcinoma
e) others lymphoma sarcoma carcinosarcoma
A definition for each major type can be found under stage information.
References:
- LiVolsi VA: Pathology of thyroid disease. In: Falk SA: Thyroid disease:
endocrinology, surgery, nuclear medicine, and radiotherapy. New York: Raven Press, 1990,
pp 127-175.
The American Joint Committee on Cancer (AJCC) has designated staging by TNM
classification.[1]
-- TNM definitions --
Primary tumor (T)
Note: All categories may be subdivided into (a) solitary tumor or (b)
multifocal tumor (the largest determines the classification)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
T1: Tumor 1 cm or less in greatest dimension limited to the thyroid
T2: Tumor more than 1 cm but not more than 4 cm in greatest dimension
limited to the thyroid
T3: Tumor more than 4 cm in greatest dimension limited to the thyroid
T4: Tumor of any size extending beyond the thyroid capsule
Regional lymph nodes (N)
Regional lymph nodes are the cervical and upper mediastinal lymph nodes.
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Regional lymph node metastasis
N1a: Metastasis in ipsilateral cervical lymph node(s)
N1b: Metastasis in bilateral, midline, or contralateral cervical or
mediastinal lymph node(s)
Distant metastases (M)
MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
-- AJCC stage groupings --
Papillary or follicular
Under 45 years
Stage I: Any T, Any N, M0
Stage II: Any T, Any N, M1
45 years and older
Stage I: T1, N0, M0
Stage II: T2, N0, M0
T3, N0, M0
Stage III: T4, N0, M0
Any T, N1, M0
Stage IV: Any T, Any N, M1
Medullary
Stage I: T1, N0, M0
Stage II: T2, N0, M0
T3, N0, M0
T4, N0, M0
Stage III: Any T, N1, M0
Stage IV: Any T, Any N, M1
Undifferentiated (anaplastic)
All cases are stage IV
Stage IV: Any T, Any N, Any M
Stage I papillary
Stage I papillary carcinoma is localized to the thyroid gland. In as many as 50% of
cases there are multifocal sites of papillary adenocarcinomas throughout the gland. Most
papillary cancers have some follicular elements, and these may sometimes be more numerous
than the papillary formations, but this does not change the prognosis. The 10-year
survival rate is slightly better for patients under 40 years of age than for patients over
40 years.
Stage II papillary
Stage II papillary carcinoma is defined as either 1) tumor that has spread distantly in
patients younger than 45 years of age or 2) tumor that is greater than 1 cm in size and is
limited to the thyroid gland in patients older than 45 years of age. In as many as 50%-80%
of cases there are multifocal sites of papillary adenocarcinomas throughout the gland.
Most papillary cancers have some follicular elements, and these may sometimes be more
numerous than the papillary formations, but this does not appear to change the prognosis.
Stage III papillary
Stage III is papillary carcinoma in patients older than 45 years of age with local
cervical invasion or positive lymph nodes. Papillary carcinoma which has invaded adjacent
cervical tissue has a worse prognosis than tumors confined to the thyroid.
Stage IV papillary
Stage IV is papillary carcinoma in patients older than 45 years of age with distant
metastases. The lungs and bone are the most frequent distant sites of spread, although
such distant spread is rare in this type of thyroid cancer. Papillary carcinoma more
frequently metastasizes to regional lymph nodes than to distant sites. The prognosis for
patients with distant metastases is poor.
Stage I follicular
Stage I follicular carcinoma is localized to the thyroid gland. Follicular thyroid
carcinoma must be distinguished from follicular adenomas, which are characterized by their
lack of invasion through the capsule into the surrounding thyroid tissue. While follicular
cancers have a good prognosis, it is less favorable than that of papillary carcinoma. The
10-year survival for patients with follicular carcinoma without vascular invasion is
better than for patients with vascular invasion.
Stage II follicular
Stage II follicular carcinoma is defined as either 1) tumor that has spread distantly
in patients younger than 45 years of age or 2) tumor that is greater than 1 cm in size and
is limited to the thyroid gland in patients older than 45 years of age. The presence of
lymph node metastases does not worsen the prognosis. Follicular thyroid carcinoma must be
distinguished from follicular adenomas, which are characterized by their lack of invasion
through the capsule into the surrounding thyroid tissue. While follicular cancers have a
good prognosis, it is less favorable than that of papillary carcinoma; the 10-year
survival for patients with follicular carcinoma without vascular invasion is better than
for patients with vascular invasion.
Stage III follicular
Stage III is follicular carcinoma in patients older than 45 years of age with local
cervical invasion or positive lymph nodes. Follicular carcinoma invading cervical tissue
has a worse prognosis than tumors confined to the thyroid gland. The presence of vascular
invasion is an additional poor prognostic factor. Metastases to lymph nodes do not worsen
the prognosis.
Stage IV follicular
Stage IV is follicular carcinoma in patients over 45 years of age with distant
metastases. The lungs and bone are the most frequent sites of spread. Follicular
carcinomas more commonly have blood vessel invasion and tend to metastasize hematogenously
to the lungs and to the bone rather than through the lymphatic system. The prognosis for
patients with distant metastases is poor.
Medullary
Several staging systems have been employed to correlate extent of disease with
long-term survival in medullary thyroid cancer. The clinical staging system of the AJCC
correlates survival to size of the primary tumor, presence or absence of lymph node
metastases, and presence or absence of distance metastasis. Patients with the best
prognosis are those who are diagnosed by provocative screening, prior to the appearance of
palpable disease.[2]
Stage I medullary
Tumor less than 1 cm in size or clinically occult disease detected by provocative
biochemical screening
Stage II medullary
Tumor greater than 1 cm but less than 4 cm
Stage III medullary
Lymph node metastasis
Stage IV medullary
Distant metastasis (any T, any N, M1)
Medullary carcinoma usually presents as a hard mass, and is often accompanied by blood
vessel invasion. Medullary thyroid cancer occurs in two forms: sporadic and familial. In
the sporadic form the tumor is usually unilateral. In the familial form, the tumor is
almost always bilateral. In addition, the familial form may be associated with benign or
malignant tumors of other endocrine organs, commonly referred to as the multiple endocrine
neoplasia syndromes (MEN-2A or MEN-2B).
In this syndrome, there is an association with pheochromocytoma of the adrenal gland
and parathyroid hyperplasia. Medullary carcinoma usually secretes calcitonin, a hormonal
marker for the tumor, and may be detectable in blood even though the tumor is clinically
occult. Metastases to regional lymph nodes are found in about 50% of cases. Prognosis
depends on extent of disease at presentation, presence or absence of regional lymph node
metastases, and completeness of the surgical resection.[3]
Family members should be screened for calcitonin elevation to identify individuals who
are at risk of developing familial medullary thyroid cancer. MEN-2A gene carrier status
can be more accurately determined by analysis of mutations in the RET gene. Whereas modest
elevation of calcitonin may lead to a false-positive diagnosis of medullary carcinoma, DNA
testing for the RET mutation is the optimal approach in evaluating MEN-2A. All patients
with medullary carcinoma of the thyroid (whether familial or sporadic) should be tested
for RET mutations, and if they are positive, then family members should also be tested.
Family members who are gene carriers should undergo prophylactic thyroidectomy at an early
age.[4,5]
Anaplastic
There is no generally accepted staging system for anaplastic thyroid cancer. All
patients are considered to have stage IV disease.
Undifferentiated (anaplastic) carcinoma tumors are highly malignant cancers of the
thyroid. They may be subclassified as small cell or large cell carcinomas. Both grow
rapidly and extend to structures beyond the thyroid. Both small cell and large cell
carcinoma present as hard, ill-defined masses, often with extension into the structures
surrounding the thyroid. Small cell anaplastic thyroid carcinoma must be carefully
distinguished from lymphoma. This tumor usually occurs in an older age group and is
characterized by extensive local invasion and rapid progression. Five-year survival with
this tumor is poor. Death is usually from uncontrolled local cancer in the neck, usually
within months of diagnosis.
References:
- Thyroid Gland. In: American Joint Committee on Cancer: AJCC Cancer Staging
Manual. Philadelphia: Lippincott-Raven Publishers, 5th ed., 1997, pp 59-64.
- Colson YL, Carty SE: Medullary thyroid carcinoma. American Journal of
Otolaryngology 14(2): 73-81, 1993.
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT,
Hellman S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Lips CJ, Landsvater RM, Hoppener JW, et al.: Clinical screening as
compared with DNA analysis in families with multiple endocrine neoplasia type 2A. New
England Journal of Medicine 331(13): 828-835, 1994.
- Decker RA, Peacock ML, Borst MJ, et al.: Progress in genetic screening
of multiple endocrine neoplasia type 2A: is calcitonin testing obsolete? Surgery 118(2):
257-264, 1995.
The designations in PDQ that treatments are "standard" or "under
clinical evaluation" are not to be used as a basis for reimbursement determinations.
Surgery is the therapy of choice for all primary lesions. Surgical options include
total thyroidectomy or lobectomy. The choice of procedure is influenced mainly by the age
of the patient and the size of the nodule. Survival results may be similar; the difference
between them lies in the rates of surgical complications and local recurrences.[1-5]
Treatment options:
Standard:
- 1. Lobectomy: This procedure is associated with a lower incidence of complications, but
approximately 5%-10% of patients will have a recurrence in the thyroid following
lobectomy. Patients under the age of 45 will have the longest follow-up period and the
greatest opportunity for recurrence. Abnormal regional lymph nodes should be biopsied at
the time of surgery. Recognized nodal involvement should be removed at initial surgery but
selective node removal can be performed and radical neck dissection is not required.
Following the surgical procedure, patients should receive postoperative treatment with
exogenous thyroid hormone in doses sufficient to suppress TSH, since studies have shown a
decreased incidence of recurrence.
I-131: Studies have shown that a postoperative course of therapeutic (ablative) doses of
I-131 results in a decreased recurrence rate in papillary and follicular carcinomas.[4] It may be given in addition to exogenous thyroid hormone, but is
not considered routine.[6] Patients presenting with papillary
thyroid microcarcinomas (tumors <10 mm) have an excellent prognosis when treated
surgically, and additional therapy with I-131 would not be expected to improve the
prognosis.[7]
2. Total thyroidectomy: This procedure is advocated because of the high incidence of
multicentric involvement of both lobes of the gland and the question of de-differentiation
of the residual tumor to the anaplastic cell type. The procedure is associated with a
higher incidence of hypoparathyroidism, but this complication may be reduced when a small
amount of tissue remains on the contralateral side. This approach facilitates follow-up
thyroid scanning.
References:
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT, Hellman
S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Grant CS, Hay ID, Gough IR, et al.: Local recurrence in papillary
thyroid carcinoma: Is extent of surgical resection important? Surgery 104(6): 954-962,
1988.
- Cady B, Rossi R: An expanded view of risk-group definition in
differentiated thyroid carcinoma. Surgery 104(6): 947-953, 1988.
- Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. American Journal of Medicine
97: 418-428, 1994.
- Staunton MD: Thyroid cancer: a multivariate analysis on influence of
treatment on long-term survival. European Journal of Surgical Oncology 20: 613-621, 1994.
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
- Hay ID, Grant CS, van Heerden JA, et al.: Papillary thyroid
microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery 112(6):
1139-1147, 1992.
Surgery is the therapy of choice for all primary lesions. Surgical options include
total thyroidectomy or lobectomy. The age of the patient and the size of the nodule
influence the selection of the operative procedure. Survival results are similar; the
difference between them lies in the rates of surgical complications and local
recurrences.[1-5]
Treatment options:
Standard:
- 1. Total thyroidectomy: This procedure is advocated because of the high incidence of
multicentric involvement of both lobes of the gland. However, it is associated with a
higher incidence of hypoparathyroidism. This complication may be reduced when a small
amount of tissue remains on the contralateral side. This approach facilitates follow-up
thyroid scanning.
2. Lobectomy: This procedure is associated with a lower incidence of complications, but
approximately 5%-10% of patients will have a recurrence in the thyroid following
lobectomy. Follicular thyroid cancer commonly metastasizes to lung and bone; with a
remnant lobe in place, use of I-131 as ablative therapy is compromised. Abnormal regional
lymph nodes should be biopsied at the time of surgery. Recognized nodal involvement should
be removed at initial surgery but selective node removal can be performed and radical neck
dissection is not required.
Following the surgical procedure, patients should receive postoperative treatment with
exogenous thyroid hormone in doses sufficient to suppress TSH, since studies have shown a
decreased incidence of recurrence.
I-131: Studies have shown that a postoperative course of therapeutic (ablative) doses of
I-131 results in a decreased recurrence rate in papillary and follicular carcinomas.[5] It should be given in addition to exogenous thyroid hormone.[6]
References:
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT, Hellman
S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Tollefsen HR, Shah JP, Huvos AG: Follicular carcinoma of the thyroid.
American Journal of Surgery 126(4): 523-528, 1973.
- Edis AJ: Surgical treatment for thyroid cancer. Surgical Clinics of
North America 57(3): 533-542, 1977.
- Staunton MD: Thyroid cancer: a multivariate analysis on influence of
treatment on long-term survival. European Journal of Surgical Oncology 20: 613-621, 1994.
- Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. American Journal of Medicine
97: 418-428, 1994.
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
Surgery is the therapy of choice for all primary lesions. Surgical options include
total thyroidectomy or lobectomy. The choice of procedure is influenced mainly by the age
of the patient and the size of the nodule. Survival results may be similar; the difference
between them lies in the rates of surgical complications and local recurrences.[1-5]
Treatment options:
Standard:
- 1. Lobectomy: This procedure is associated with a lower incidence of complications, but
approximately 5%-10% of patients will have a recurrence in the thyroid following
lobectomy. Patients under the age of 45 will have the longest follow-up period and the
greatest opportunity for recurrence. Abnormal regional lymph nodes should be biopsied at
the time of surgery. Recognized nodal involvement should be removed at initial surgery but
selective node removal can be performed and radical neck dissection is not required. This
results in a decreased recurrence rate, but has not been shown to improve survival.
Following the surgical procedure, patients should receive postoperative treatment with
exogenous thyroid hormone in doses sufficient to suppress TSH, since studies have shown a
decreased incidence of recurrence.
I-131: Studies have shown that a postoperative course of therapeutic (ablative) doses of
I-131 results in a decreased recurrence rate in papillary and follicular carcinomas.[5] It may be given in addition to exogenous thyroid hormone, but is
not considered routine.[6]
2. Total thyroidectomy: This procedure is advocated because of the high incidence of
multicentric involvement of both lobes of the gland and the question of de-differentiation
of the residual tumor to the anaplastic cell type. The procedure is associated with a
higher incidence of hypoparathyroidism, but this complication may be reduced when a small
amount of tissue remains on the contralateral side. This approach facilitates follow-up
thyroid scanning.
References:
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT, Hellman
S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Grant CS, Hay ID, Gough IR, et al.: Local recurrence in papillary
thyroid carcinoma: Is extent of surgical resection important? Surgery 104(6): 954-962,
1988.
- Cady B, Rossi R: An expanded view of risk-group definition in
differentiated thyroid carcinoma. Surgery 104(6): 947-953, 1988.
- Staunton MD: Thyroid cancer: a multivariate analysis on influence of
treatment on long-term survival. European Journal of Surgical Oncology 20: 613-621, 1994.
- Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. American Journal of Medicine
97: 418-428, 1994.
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
Surgery is the therapy of choice for all primary lesions. Surgical options include near
total thyroidectomy and lobectomy. The age of the patient and the size of the nodule
influence the selection of the operative procedure. Survival results are similar; the
difference between them lies in the rates of surgical complications and local
recurrences.[1-3]
Treatment options:
Standard:
- 1. Total thyroidectomy: This procedure is advocated because of the high incidence of
multicentric involvement of both lobes of the gland. However, it is associated with a
higher incidence of hypoparathyroidism. This complication is reduced when a small amount
of tissue remains on the contralateral side. This approach facilitates follow-up thyroid
scanning.
2. Lobectomy: This procedure is associated with a lower incidence of complications, but
approximately 5%-10% of patients will have a recurrence in the thyroid following
lobectomy. Follicular thyroid cancer commonly metastasizes to lung and bone; with a
remnant lobe in place, use of I-131 as ablative therapy is compromised. Abnormal regional
lymph nodes should be biopsied at the time of surgery. Recognized nodal involvement should
be removed at initial surgery but selective node removal can be performed and radical node
dissection is not required.
Following the surgical procedure, patients should receive postoperative treatment with
exogenous thyroid hormone in doses sufficient to suppress TSH, since studies have shown a
decreased incidence of recurrence.
I-131: Studies have shown that a postoperative course of therapeutic (ablative) doses of
I-131 results in a decreased recurrence rate in papillary and follicular carcinomas. It
should be given in addition to exogenous thyroid hormone.[4]
References:
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT, Hellman
S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Tollefsen HR, Shah JP, Huvos AG: Follicular carcinoma of the thyroid.
American Journal of Surgery 126(4): 523-528, 1973.
- Edis AJ: Surgical treatment for thyroid cancer. Surgical Clinics of
North America 57(3): 533-542, 1977.
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
Treatment options:
Standard:
- 1. Total thyroidectomy plus removal of involved lymph nodes.
2. I-131 ablation following total thyroidectomy if the tumor demonstrates uptake of this
isotope.[1]
3. External-beam irradiation if I-131 uptake is minimal.
References:
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
Treatment options:
Standard:
- 1. Total thyroidectomy plus removal of involved lymph nodes or other sites of
extrathyroid disease.
2. I-131 ablation following total thyroidectomy if the tumor demonstrates uptake of this
isotope.[1]
3. External-beam irradiation if I-131 uptake is minimal.[2]
References:
- Beierwaltes WH, Rabbani R, Dmuchowski C, et al.: An analysis of
"Ablation of Thyroid Remnants" with I-131 in 511 patients from 1947-1984:
experience at University of Michigan. Journal of Nuclear Medicine 25(12): 1287-1293, 1984.
- Simpson WJ, Carruthers JS: The role of external radiation in the
management of papillary and follicular thyroid cancer. American Journal of Surgery 136(4):
457-460, 1978.
The most common sites of metastases are lymph nodes, lung, and bone. Treatment of lymph
node metastases alone is often curative. Treatment of distant metastases is usually not
curative but may produce significant palliation.
Treatment options:
Standard:
- Distant metastases:
- 1. I-131: Metastases which demonstrate uptake of this isotope may be ablated by
therapeutic doses of I-131.
2. External-beam irradiation for patients with localized lesions that are unresponsive to
I-131.[1]
3. TSH suppression with T-4 is also effective in many of the non I-131 sensitive lesions.
4. Patients unresponsive to I-131 should also be considered candidates for investigative
protocols testing new approaches to this disease.
Under clinical evaluation:
- Clinical trials evaluating new treatment approaches to this disease should
also be considered for these patients. Chemotherapy has been reported to
produce occasional complete responses of long duration.[2-4] Refer to PDQ
or to CancerNet (http://cancernet.nci.nih.gov)
for information on clinical
trials for patients with thyroid cancer.
References:
- Simpson WJ, Carruthers JS: The role of external radiation in the
management of papillary and follicular thyroid cancer. American Journal of Surgery 136(4):
457-460, 1978.
- Gottlieb JA, Hill CS, Ibanez ML, et al.: Chemotherapy of thyroid
cancer: an evaluation of experience with 37 patients. Cancer 30(3): 848-853, 1972.
- Marada T, Nishikawa Y, Suzuki T, et al.: Bleomycin treatment for
cancer of the thyroid. American Journal of Surgery 122(1): 53-57, 1971.
- Shimaoka K, Schoenfeld DA, DeWys WD, et al.: A randomized trial of
doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma.
Cancer 56(9): 2155-2160, 1985.
Treatment of distant metastases is usually not curative but may produce significant
palliation.
Treatment options:
Standard:
- Distant metastases:
- 1. I-131: Metastases which demonstrate uptake of this isotope may be ablated by
therapeutic doses of I-131.
2. External-beam irradiation for patients with localized lesions that are unresponsive to
I-131.[1]
3. TSH suppression with T-4 is also effective in many of the non I-131 sensitive lesions.
4. Patients unresponsive to I-131 should also be considered candidates for investigative
protocols testing new approaches to this disease.
Under clinical evaluation:
- Clinical trials evaluating new treatment approaches to this disease should
also be considered for these patients. Chemotherapy has been reported to
produce occasional complete responses of long duration.[2-4] Refer to
PDQ or to CancerNet (http://cancernet.nci.nih.gov)
for information on
clinical trials for patients with thyroid cancer.
References:
- Simpson WJ, Carruthers JS: The role of external radiation in the
management of papillary and follicular thyroid cancer. American Journal of Surgery 136(4):
457-460, 1978.
- Gottlieb JA, Hill CS, Ibanez ML, et al.: Chemotherapy of thyroid
cancer: an evaluation of experience with 37 patients. Cancer 30(3): 848-853, 1972.
- Marada T, Nishikawa Y, Suzuki T, et al.: Bleomycin treatment for
cancer of the thyroid. American Journal of Surgery 122(1): 53-57, 1971.
- Shimaoka K, Schoenfeld DA, DeWys WD, et al.: A randomized trial of
doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma.
Cancer 56(9): 2155-2160, 1985.
Patients with medullary thyroid cancer should be treated with a total thyroidectomy,
unless there is evidence of distant metastasis. There should be careful sampling of the
regional lymph nodes, unless others appear abnormal. If regional lymph nodes are involved,
a (modified) radical neck dissection should be done.[1] When
cancer is confined to the thyroid gland virtually all patients will be cured. Any patient
with a familial variant should be screened for other endocrine tumors, particularly
parathyroid hyperplasia and pheochromocytoma.[2,3] Chemotherapy has been reported to produce occasional responses in
metastatic disease.[4] Refer to PDQ or to CancerNet (http://cancernet.nci.nih.gov) for information on
clinical trials for patients with thyroid cancer.
Family members should be screened for calcitonin elevation and/or MEN-2A gene carrier
status to identify other individuals at risk for developing familial medullary thyroid
cancer. All patients with medullary carcinoma of the thyroid (whether familial or
sporadic) should ideally be tested for RET mutations, and if they are positive, then
family members can also be tested. Whereas modest elevation of calcitonin may lead to a
false-positive diagnosis of medullary carcinoma, DNA testing for the RET mutation is the
optimal approach in evaluating MEN-2A syndrome. Family members who are gene carriers
should undergo prophylactic thyroidectomy at an early age.[5,6]
References:
- Bloch MA, Jackson CE, Tashjian AH: Management of occult medullary thyroid
carcinoma. Archives of Surgery 113(4): 368-372, 1978.
- Norton JA, Froome LC, Farrell RE, et al.: Multiple endocrine
neoplasia type IIb: the most aggressive form of medullary thyroid carcinoma. Surgical
Clinics of North America 59(1): 109-118, 1979.
- Saad MF, Ordonez NG, Rashid RK, et al.: Medullary carcinoma of the
thyroid: a study of the clinical features and prognostic factors in 161 patients. Medicine
63(6); 319-342, 1984.
- Shimaoka K, Schoenfeld DA, DeWys WD, et al.: A randomized trial of
doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma.
Cancer 56(9): 2155-2160, 1985.
- Lips CJ, Landsvater RM, Hoppener JW, et al.: Clinical screening as
compared with DNA analysis in families with multiple endocrine neoplasia type 2A. New
England Journal of Medicine 331(13): 828-835, 1994.
- Decker RA, Peacock ML, Borst MJ, et al.: Progress in genetic
screening of multiple endocrine neoplasia type 2A: is calcitonin testing obsolete? Surgery
118(2): 257-264, 1995.
Treatment options:
Standard:
- 1. Surgery: Tracheostomy is frequently necessary. If the disease remains in the local
area, which is indeed rare, total thyroidectomy is warranted to reduce symptoms caused by
the tumor mass.[1,2]
2. Radiation therapy: External beam radiotherapy may be employed in those patients who are
not surgical candidates or whose tumor cannot be surgically excised.
3. Chemotherapy: Anaplastic thyroid cancer is not responsive to I-131 therapy; treatment
with single anticancer drugs has been reported to produce partial remissions in some
patients. Approximately 30% of patients achieve partial remission with doxorubicin.[3] The combination of doxorubicin plus cisplatin appears to be more
active than doxorubicin alone and has been reported to produce more complete responses.[4]
Under clinical evaluation:
- Clinical trials evaluating new treatment approaches for this disease should
also be considered.[5] Refer to PDQ or to CancerNet
(http://cancernet.nci.nih.gov) for information
on clinical trials for
patients with thyroid cancer.
References:
- Goldman JM, Goren EN, Cohen MH, et al.: Anaplastic thyroid carcinoma:
long-term survival after radical surgery. Journal of Surgical Oncology 14(4): 389-394,
1980.
- Aldinger KA, Samaan NA, Ibanez ML, et al.: Anaplastic carcinoma of
the thyroid: a review of 84 cases of spindle and giant cell carcinoma of the thyroid.
Cancer 41(6): 2267-2275, 1978.
- Fraker DL, Skarulis M, Livolsi V: Thyroid tumors. In: DeVita VT,
Hellman S, Rosenberg SA, Eds.: Cancer: Principles and Practice of Oncology. Philadelphia:
Lippincott-Raven Publishers, 5th ed., 1997, pp 1629-1652.
- Shimaoka K, Schoenfeld DA, DeWys WD, et al.: A randomized trial of
doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma.
Cancer 56(9): 2155-2160, 1985.
- O'Mara R, Kartchner M, Salmon SE: High-risk thyroid cancer. Cancer
Clinical Trials 4(1): 67-73, 1981.
Patients treated for differentiated thyroid cancer should be followed carefully with
physical examinations, thyroglobulin levels, and radiologic studies based on individual
risk for recurrent disease.[1] Approximately 10%-30% of patients
felt to be disease-free after initial treatment will develop recurrence and/or metastases.
Of patients who recur, approximately 80% recur with disease in the neck alone and 20% with
distant metastases. The most common site of distant metastasis is the lung. In one series
of 289 patients who developed recurrences after initial surgery, 16% died of cancer at a
median time of five years following recurrence.[2] The prognosis
for patients with clinically detectable recurrences is generally poor, regardless of cell
type.[3] However, those patients who recur with local or regional
tumor detected only by I-131 scan have a better prognosis.[4] The
selection of further treatment depends on many factors, including cell type, uptake of
I-131, prior treatment, site of recurrence, and individual patient considerations. Surgery
with or without I-131 ablation can be useful in controlling local recurrences, regional
node metastases, or occasionally metastases at other localized sites. Approximately half
of the patients operated on for recurrent tumor can be rendered free of disease with a
second operation.[3] Local and regional recurrences detected by
I-131 scan and not clinically apparent can be treated with I-131 ablation and have an
excellent prognosis.[5]
Up to 25% of recurrences and metastases from well-differentiated thyroid cancer may not
show I-131 uptake. For these patients, other imaging techniques shown to be of value
include imaging with thallium-201, magnetic resonance imaging, and pentavalent
dimercaptosuccinic acid.[6] When recurrent disease does not
concentrate I-131, external-beam or intraoperative radiation therapy can be useful in
controlling symptoms related to local tumor recurrences.[7]
Systemic chemotherapy can be considered. Chemotherapy has been reported to produce
occasional objective responses, usually of short duration.[4,8] Clinical trials evaluating new treatment approaches should also
be considered. Refer to PDQ or to CancerNet (http://cancernet.nci.nih.gov)
for information on clinical trials for patients with recurrent thyroid cancer.
References:
- Ross DS: Long-term management of differentiated thyroid cancer.
Endocrinology and Metabolism Clinics of North America 19(3): 719-739, 1990.
- Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and
medical therapy on papillary and follicular thyroid cancer. American Journal of Medicine
97: 418-428, 1994.
- Goretzki PE, Simon D, Frilling A, et al.: Surgical reintervention for
differentiated thyroid cancer. British Journal of Surgery 80(8): 1009-1012, 1993.
- De Besi P, Busnardo B, Toso S, et al.: Combined chemotherapy with
bleomycin, adriamycin, and platinum in advanced thyroid cancer. Journal of
Endocrinological Investigation 14(6): 475-480, 1991.
- Coburn M, Teates D, Wanebo HJ: Recurrent thyroid cancer: role of
surgery versus radioactive iodine (I131). Annals of Surgery 219(6): 587-595, 1994.
- Mallin WH, Elgazzar AH, Maxon HR: Imaging modalities in the follow-up
of non-Iodine avid thyroid carcinoma. American Journal of Otolaryngology 15(6): 417-422,
1994.
- Vikram B, Strong EW, Shah JP, et al.: Intraoperative radiotherapy in
patients with recurrent head and neck cancer. American Journal of Surgery 150(4): 485-487,
1985.
- Shimaoka K, Schoenfeld DA, DeWys WD, et al.: A randomized trial of
doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma.
Cancer 56(9): 2155-2160, 1985.
Date Last Modified: 08/98
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