Thyroid Cancer: A Brief Guide to Diagnosis and Treatment

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These drugs target the signals that tell cancer cells to grow and divide. They're used in people with advanced thyroid cancer. Palliative care is specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness. Palliative care specialists work with you, your family and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing other aggressive treatments, such as surgery, chemotherapy or radiation therapy. When palliative care is used along with all of the other appropriate treatments, people with cancer may feel better and live longer.

Palliative care is provided by a team of doctors, nurses and other specially trained professionals. Palliative care teams aim to improve the quality of life for people with cancer and their families. This form of care is offered alongside curative or other treatments you may be receiving. Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease. A diagnosis of thyroid cancer can be frightening. You might feel as if you aren't sure what to do next. Everyone eventually finds his or her own way of coping with a cancer diagnosis.

Until you find what works for you, consider trying to:. If you have signs and symptoms that worry you, start by seeing your family doctor. If your doctor suspects you may have a thyroid problem, you may be referred to a doctor who specializes in diseases of the endocrine system endocrinologist. Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well-prepared. Here's some information to help you get ready, and what to expect from your doctor. Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together.

List your questions from most important to least important in case time runs out. For thyroid cancer, some basic questions to ask your doctor include:. Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth.

Your doctor may ask:. Thyroid cancer care at Mayo Clinic. Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. This content does not have an English version. This content does not have an Arabic version. Thyroid biopsy During a thyroid biopsy, your doctor uses a needle to remove a small amount of suspicious tissue from your thyroid gland. Parathyroid glands The parathyroid glands, which lie behind the thyroid, manufacture the parathyroid hormone, which plays a role in regulating your body's levels of the minerals calcium and phosphorus.

Request an Appointment at Mayo Clinic. Share on: Facebook Twitter. References AskMayoExpert. Anaplastic thyroid cancer. Rochester, Minn. Differentiated thyroid cancers. Medullary thyroid cancer. Melmed S, et al.


Nontoxic diffuse goiter, nodular thyroid disorders and thyroid malignancies. In: Williams Textbook of Endocrinology. Philadelphia, Pa. Accessed Dec. Thyroid carcinoma. Fort Washington, Pa. Niederhuber JE, et al. Cancer of the endocrine system. In: Abeloff's Clinical Oncology. Fact sheet: Guidelines for patients receiving radioiodine I treatment. Society for Nuclear Medicine and Molecular Imaging. Its main advantages are simplicity and safety; its main disadvantage is that insufficient I may be administered to adequately treat tumor Lymph node metastases too small to excise are treated with about — mCi.

Cancer growing through the thyroid capsule is treated with — mCi, and patients with distant metastases are usually treated with mCi, which will not induce severe radiation sickness or produce serious damage to critical structures 44 , Diffuse pulmonary metastases that intensely concentrate I are treated with an amount estimated to result in a whole body activity of less than 80 mCi after 48 h to avoid lung injury, which as a practical matter is about mCi Experience with I therapy for children is limited, but it seems to be effective in most with nodal or pulmonary metastases, with only a small increased risk of developing other cancers Reynolds 93 has shown that the amount of I resulting in the same absorbed dose to a child as an adult given 1 mCi is linearly related to body weight and to body surface area.

The fraction of an adult dose is 0. Although it is generally held that to eradicate a tumor at least 0. A second approach is to use quantitative dosimetry to estimate tumor I uptake and retention, which some favor because radiation exposure from arbitrarily fixed doses of I can vary considerably from ineffective to excessive.

The therapy dose is calculated to deliver an acceptable radiation dose to the lesion usually nodal or discrete soft tissue metastases without exceeding safety limits to the blood bone marrow and whole body. The data are collected one or more times daily over 72—96 h as an outpatient The cancer is unlikely to respond to I therapy if the tumor dose is less than 3, rad 35 Gy , in which case it should be considered for surgery, external radiation, or medical therapy 23 , Below 8, cGy, success starts to become questionable It is necessary to estimate tumor or remnant size to make these calculations, which may be difficult, for example with diffuse microscopic lung metastases.

In this case, the dose is based on the calculated safety limit to the bone marrow and whole body A third method is to administer the largest safe dose of I based on dosimetric calculations. Pioneering work done by Benua et al. This occurred in a patient with skeletal metastases who was given mCi that delivered cGy to the blood in whom h whole-body retention was 81 mCi. The currently accepted upper dose limit is calculated to deliver a maximum of cGy to the whole blood while keeping the whole body retention less than mCi at 48 h, or less than 80 mCi when there is diffuse pulmonary uptake Severe complications from these single large amounts are infrequent 96 , but not absent The drug enhances I retention probably as a result of its inhibitory effect on iodine release from both normal and neoplastic follicular cells Radiation of tumors in which the biologic half-life of iodine is less than 6 days is maximized without increasing radiation to other organs, whereas the largest increase in tumor radiation occurs in lesions with a biological half-life of less than 3 days Serum lithium levels should be measured daily and maintained between 0.

The drug may be continued for 5—7 days after therapy, but lithium levels cannot be measured immediately after I therapy and one must carefully avoid lithium toxicity during this time.

A few patients with tumor that does not concentrate I may benefit from retinoic acid. The drug partly redifferentiates follicular thyroid cancer in vitro , but when it was given orally 1.

Initial Surgical Management

A positive response was associated with a rise in serum Tg concentration, suggesting tumor redifferentiation. About two thirds of patients given mCi or more develop mild radiation sickness characterized by headache, nausea, and vomiting that begins about 4 h after I administration and resolves within 24 h 65 , The most important acute complication of I therapy is I-induced tumor edema or hemorrhage, which may occur rapidly and is most serious with tumor in the brain, spinal cord, or airway Pretreatment with corticosteroids and mannitol may minimize this hazard , but patients must be hospitalized and closely observed.

Surgical debulking of spinal lesions may be prudent before I is given, and surgery may be the treatment of choice for operable brain metastases Pain in distant metastases can occur shortly after I therapy as a result of radiation-induced inflammation, which can also cause vocal cord paralysis when a large amount of functioning thyroid tissue is in close proximity to the vocal cords or recurrent laryngeal nerves 65 , Transient peripheral facial nerve palsy was reported in two patients after high-dose I therapy, presumably due to radiation of the nerve as it courses through the parotid area It usually appears within the first week after I administration and is recognized by neck and ear pain, painful swallowing, thyroid swelling and tenderness, and transient mild thyrotoxicosis.

A large thyroid remnant may rarely swell enough to cause airway obstruction or can cause serious thyrotoxicosis. Mild pain can be treated with salicylate, a nonsteroidal anti-inflammatory drug, or acetaminophen, but severe pain or swelling requires corticosteroid therapy. Symptoms may occur within 24 h of treatment and are more likely when large amounts of I have been given to a patient with little functioning thyroid tissue Chewing gum, sucking on lemon candies, and hydration during the I treatment might prevent sialadenitis and xerostomia.

Transient tongue pain or reduced taste also may occur Intermittent tender salivary gland swelling may occur for some months due to temporary obstruction by a thick salivary plug that often occurs after eating. Decompression is often associated with a salty taste and usually occurs spontaneously. Despite these symptoms, invasive therapy is not required and it usually improves spontaneously within about a year; however, some develop chronic xerostomia. Although nearly half the patients eventually have reduced salivary gland function and some report recurrent conjunctivitis, these are almost never serious problems A slight reduction in platelets and white-cell counts may occur after I therapy but is transient and typically asymptomatic More severe bone marrow suppression with anemia can follow very large doses of I, but this typically is reversible and does not require blood transfusions Grave hematological depression is unlikely when the I dose delivers less than cGy to the blood The serious long-term complications of I are damage to the gonads, bone marrow and lungs, and the induction of other cancers.

The miscarriage rate almost doubles during the year after surgery for thyroid cancer, both before and after I therapy, and doubles again after I therapy of more than mCi. Whether this relates more to gonadal irradiation or to insufficient control of hormonal thyroid status is uncertain, but the fact that the rate of miscarriage after treatment with more than mCi is twice that after treatment with less than mCi suggests a role for irradiation in this phenomenon In a long-term study, fertility was normal in 30 patients who were aged 30 yr or less when treated, after which they had 44 live births The testis is even more sensitive to irradiation than is the ovary.

A single administration of 50— mCi may deliver sufficient radiation to the testes to cause transient testicular failure of uncertain long-term consequence Young men may develop permanent testicular damage with reduced sperm counts roughly proportional to the amount of I administered The only manifestation may be asymptomatic FSH elevation; however, after several I treatments, this may be associated with reduced sperm motility, although serum testosterone usually remains normal It, thus, seems prudent to consider banking sperm in young men treated with I, especially if the cumulative dose is anticipated to be over mCi.

There is no evidence that treating children or women during the childbearing years increases the risk of congenital abnormalities.

Thyroid Cancers: Considerations, Classifications, and Managements

In a long-term study of 33 children treated at an average age of A study of pregnancies in females treated for thyroid cancer found that the incidences of stillbirth, preterm birth and low birth weight, congenital malformation, and death during the first year of life were not significantly different before and after I therapy Bone marrow damage and induction of other tumors are the most serious late sequelae of I therapy. Cumulative amounts of I over mCi cause a small but significant excess of deaths from bladder cancer and leukemia Bladder cancer is more likely in those with relatively little I uptake in the neck or metastases There is an increased risk of colorectal cancer 5 or more years after I therapy that is related to the cumulative activity of I administered This is probably caused by accumulation of I in the colon, especially in hypothyroid patients, underscoring the importance of ensuring one to two large bowel movements for a few days after I administration, which may require a laxative that does not contain iodine.

Magnesium citrate should be used with caution in patients taking lithium. In 13 large series comprising a total of patients with thyroid cancer, 14 cases of leukemia were detected , resulting in a prevalence of about 5 leukemia cases per patients 0. Acute myeloid leukemia, the type associated with I therapy, usually occurs within 2—10 yr of treatment.

It is less likely when I is given annually rather than every few months, and when total blood dose per administration is less than cGy Despite these reports, the lifetime risk of leukemia is so small 0. The estimated absolute risk of life lost from recurrent thyroid cancer exceeds that from leukemia by 4- to fold, depending on the age at which the patient is treated When I is given at month intervals and at lower total cumulative I activities — mCi , long-term effects on the bone marrow are minimal 96 and few cases of leukemia occur.

After a mean follow-up of 10 yr, no cases of leukemia were observed 2. The risk is small enough that a population study did not find an increased risk of leukemia in patients treated with I for thyroid cancer Lung fibrosis may occur in patients with diffuse pulmonary metastases treated with I 94 , — It can be avoided by using smaller I doses — mCi when a diagnostic scan shows intense uptake in the lungs. Management of a pregnant woman may be associated with considerable anxiety, mainly regarding the timing and recommendations for treatment.

Although there are case reports that pregnancy may accelerate the course of the disease, a large study shows the prognosis of newly diagnosed DTC in pregnancy is similar to that occurring in similarly aged nonpregnant women Surgery should be considered in the second trimester, but I scans and treatment can be safely delayed until after delivery. Serum Tg determinations and WBS together will detect DTC in most patients who have undergone total thyroid ablation; however, both studies are insensitive in patients who have undergone lobectomy.

After thyroid ablation has been achieved, serum Tg and WBS should be done periodically after discontinuing l -thyroxine or administering rhTSH.

Tg can be measured while the patient is taking l -thyroxine, but the test is more sensitive when l -thyroxine has been stopped or rhTSH is given to elevate the serum TSH 78 , About 4—7 days after I therapy is given, a WBS should be done to document I uptake by the tumor, which may show lesions not detected by the diagnostic scan Table 4 ; Refs. Scans were selected for analysis when both diagnostic and therapeutic scans were performed, which was based on either a measurable serum Tg level, uptake on the diagnostic scan, or other clinical indications for treatment such as a positive chest x-ray or palpable disease.

The average age at the time of initial therapy was The primary tumor diameter was 3. Ten patients with distant metastases had 12 scans. Diagnostic scans were performed with 4. During follow-up, periodic elevation of serum TSH levels to stimulate Tg release and I uptake for WBS is the optimal way to detect residual thyroid tissue or cancer. The first found that WBS results after two 0. A second multicenter international study was done to test the effects of two rhTSH dosing schedules on WBS and serum Tg levels compared with those obtained after l -thyroxine withdrawal.

The scanning method was more carefully standardized, taking into account the lower renal I clearance in hypothyroidism than after rhTSH The recommended dose of rhTSH, 0. Whole-body images are acquired after 30 min of scanning or after , counts. This is necessary because 4 mCi I after rhTSH has about the same effect as 2 mCi given during hypothyroidism with reduced renal clearance and raised body I retention A serum Tg of 2.

The drug is well tolerated. Transient headache 7. Serum Tg measurement is the best means of detecting normal and malignant thyroid tissue because there are no other sources to falsely elevate it. Most patients who are free of disease have undetectable serum Tg levels 11 , Immunometric assay IMA methods are prone to underestimating the serum Tg level when TgAbs are present, increasing the risk of a false negative test Changes in posttreatment serum TgAb levels directly correlate with the presence or absence of disease The first serum Tg after surgery is a good prognosticator.

Thereafter, Tg should be measured when TSH has been stimulated by l -thyroxine withdrawal or rhTSH stimulation, which lowers the false negative rate well below that of WBS 11 , 78 , A Tg messenger RNA method is more sensitive than the IMA method, particularly during l -thyroxine treatment or when TgAbs are present, but the test is not yet widely available Tg and WBS are usually considered complementary Nonetheless, patients with undetectable TSH-stimulated Tg levels alone rarely have cancer In lieu of a diagnostic WBS performed 1 yr after thyroid ablation, serum Tg measurement after l -thyroxine withdrawal or rhTSH stimulation may serve as a guide for the selection of patients who might have persistent cancer Pulmonary metastases sometimes may be found only after administrating large doses of I and obtaining a posttreatment WBS In another study, all but 1 of 17 patients with elevated serum Tg levels and a negative 5-mCi diagnostic scan had I uptake after 75— mCi; more than half had lung metastases Treatment of pulmonary metastases found only on posttherapy scans usually reduces the tumor burden, but complete eradication of metastases may nonetheless be difficult to achieve Recurrence rates, including those of distant metastases, are significantly reduced with l -thyroxine therapy 3 , 54 , but the optimal TSH level required to achieve this is uncertain.

However, a prospective United States study of patients in the National Thyroid Cancer Treatment Cooperative Study found that disease stage, patient age, and I therapy independently predicted disease progression, but that the degree of TSH suppression did not Tg levels often cannot be lowered by maximally suppressing TSH levels These data do not support the concept that suppressing TSH to undetectable, thyrotoxic ranges is required to prevent disease progression. As a practical matter, the most appropriate l -thyroxine dose usually is that which reduces the serum TSH to just below the lower limit of the normal range for the assay being used, unless there is persistent disease when lower levels may be necessary Recurrence-free survival, especially in patients over age 40 with invasive papillary thyroid cancer T4 and lymph node metastases N1 , may be improved by external radiation therapy 17 , Based on regression modeling of patients without distant metastases at the time of initial therapy and including surgical and I therapy, the likelihood of death from DTC was increased by multiple factors, including age over 40 yr, tumor size more than 1.

Cancer mortality was favorably and independently affected by female gender, surgery more extensive than lobectomy vs. Treatment with I to ablate the thyroid remnant and to treat residual disease were independent prognostic variables that favorably influenced recurrence, distant recurrence, and cancer death rates Table 2. These data and similar work by others confirm the importance of meticulous initial therapy, which has a lasting and favorable effect on most patients with DTC, especially those whose disease is discovered at an early stage. The patient data reported herein was derived from a follow-up study approved by the Ohio State University Institutional Review Board, and patients signed appropriate informed consent forms for therapy.

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Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Initial Surgical Management. Diagnostic I WBSs. Radioiodine I Therapy for Residual Disease.

Guidelines from American Thyroid Association

Assessment after Initial Surgical and I Treatment. External Radiation Therapy. Oxford Academic. Google Scholar. Richard T. Article history. Revision Received:. Cite Citation. Permissions Icon Permissions. Figure 1. View large Download slide. Table 1. Risk stratification of variables influencing cancer recurrence and cancer death. View Large. Table 2. Table 3. Thyroid remnant ablation effect on recurrence and cancer-specific mortality 1. Table 4. Here and elsewhere, data are an updated analysis of a patient cohort last reported by us in 3.

Here and elsewhere, age refers to patient age at the time of initial therapy. Patients under age 45 with any T, any N, and M0 are stage 1; and M1 are stage 2. Search ADS. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Schlumberger MJ. J Endocrinol Invest. Immediate causes of death in thyroid carcinoma: clinicopathological analysis of fatal cases. NCCN thyroid carcinoma practice guidelines. Prognostic significance of histologic grading compared with subclassification of papillary thyroid carcinoma.

Does the method of management of papillary thyroid carcinoma make a difference in outcome? Is diagnostic iodine scanning useful after total thyroid ablation for differentiated thyroid cancer? Prospective multicenter study of thyroid carcinoma treatment—initial analysis of staging and outcome. Initial results from a prospective cohort study of cases of thyroid carcinoma treated in the United States during Van De Velde. Report of the consensus development conference on the management of differentiated thyroid cancer in the Netherlands. The management of differentiated thyroid cancer in Europe in Results of an international survey.

Current trends in the management of well differentiated papillary thyroid carcinoma. Differentiated thyroid cancer—Impact of adjuvant external radiotherapy in patients with perithyroidal tumor infiltration stage pT4. The effects of surgery, radioiodine, and external radiation therapy on the clinical outcome of patients with differentiated thyroid carcinoma. Papillary and follicular thyroid cancer: impact of treatment in patients. Management of the solitary thyroid nodule: results of a North American survey.

Effect of early referral to an endocrinologist on efficiency and cost of evaluation and development of treatment plan in patients with thyroid nodules. Absence of thyroid stunning after diagnostic whole-body scanning with MBq I. Radioiodine therapy for well-differentiated thyroid cancer—a quantitative radiation dosimetric approach: outcome and validation in 85 patients.

Unilateral total lobectomy: is it sufficient surgical treatment for patients with AMES low-risk papillary thyroid carcinoma? Our AMES is true: how an old concept still hits the mark—or, risk group assignment points the arrow to rational therapy selection in differentiated thyroid cancer.

Prognostic factors and risk group analysis in follicular carcinoma of the thyroid. Ipsilateral lobectomy versus bilateral lobar resection in papillary thyroid carcinoma: a retrospective analysis of surgical outcome using a novel prognostic scoring system. Pulmonary metastases in differentiated thyroid carcinoma. Study of 58 cases with implications for the primary tumor treatment. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. Completion total thyroidectomy in children with thyroid cancer secondary to the Chernobyl accident.

La Quaglia. Differentiated thyroid cancer: clinical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. Local control in differentiated thyroid carcinoma with extrathyroidal invasion. Surgical management of thyroid masses: assessing the need for frozen section evaluation.

Influence of triiodothyronine withdrawal time on I uptake postthyroidectomy for thyroid cancer. The incidence of bilateral well-differentiated thyroid cancer found at completion thyroidectomy. Completion thyroidectomy in patients with differentiated thyroid carcinoma. Prophylactic thyroidectomy in 75 children and adolescents with hereditary medullary thyroid carcinoma: German and Austrian experience. Hypocalcemia following thyroid surgery: incidence and prediction of outcome. The impact of initial surgical management on outcome in young patients with differentiated thyroid cancer.

The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Thyroid remnant I ablation for papillary and follicular thyroid carcinoma. Pulmonary metastases in children and young adults with differentiated thyroid cancer. Serum thyroglobulin autoantibodies: Prevalence, influence on serum thyroglobulin measurement, and prognostic significance in patients with differentiated thyroid carcinoma.

The use of radioactive iodine in patients with papillary and follicular thyroid cancer. Prognostic value of thyroglobulin after thyroidectomy before ablative radioiodine therapy in thyroid cancer. Use of radioactive iodine in patients with papillary and follicular thyroid cancer: towards a selective approach. Radioiodine I therapy in the management of thyroid cancer.

A prospective study. Radiation exposure from outpatient radioactive iodine I therapy for thyroid carcinoma. Ablation of the thyroid remnant and I dose in differentiated thyroid cancer. Prospective randomized clinical trial to evaluate the optimal dose of I for remnant ablation in patients with differentiated thyroid carcinoma. Prescribing iodine based on neck uptake produces effective thyroid ablation and reduced hospital stay. Comparison of MBq and MBq iodine in postoperative ablation of residual thyroid tissue in patients with differentiated thyroid cancer.

Thyroid cancer - Diagnosis and treatment - Mayo Clinic

Enolase isozymes in differentiated and undifferentiated medullary thyroid carcinomas. Influence of diagnostic radioiodines on the uptake of ablative dose of iodine Decreased uptake of therapeutic doses of iodine after MBq iodine diagnostic imaging for thyroid remnants in differentiated thyroid carcinoma.

Influence of scanning doses of iodine on subsequent first ablative treatment outcome in patients operated on for differentiated thyroid carcinoma. Predicting the efficacy of first iodine treatment in differentiated thyroid carcinoma. A comparison of recombinant human thyrotropin and thyroid hormone withdrawal for the detection of thyroid remnant or cancer.

Clinical significance of hepatic visualization on iodine whole-body scan in patients with thyroid carcinoma. Radioiodide treatment of pulmonary metastases of differentiated thyroid cancer.