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Thyroid Cancer Treatment (PDQ®)


General Information About Thyroid Cancer
Cellular Classification of Thyroid Cancer
Stage Information for Thyroid Cancer
Treatment Option Overview for Thyroid Cancer
Papillary and Follicular Thyroid Cancer
Medullary Thyroid Cancer (MTC)
Anaplastic Thyroid Cancer
Changes to This Summary (05/12/2017)
About This PDQ Summary

General Information About Thyroid Cancer

There are four main types of thyroid cancer:

For clinical management of the patient, thyroid cancer is generally divided into two categories: [1]

  1. Well-differentiated tumors (papillary or follicular).
  2. Poorly differentiated tumors (medullary or anaplastic).

Well-differentiated tumors are highly treatable and usually curable. Poorly differentiated tumors are less common, aggressive, metastasize early, and have a poorer prognosis.

The thyroid gland may occasionally be the site of other primary tumors, including sarcomas, lymphomas, epidermoid carcinomas, and teratomas. The thyroid may also be the site of metastasis from other cancers, particularly of the lung, breast, and kidney.

Incidence and Mortality

Estimated new cases and deaths from thyroid cancer in the United States in 2017: [2]

Thyroid cancer affects women more often than men and usually occurs in people aged 25 to 65 years. The incidence of this malignancy has been increasing over the last decade. Thyroid cancer commonly presents as a so-called cold nodule. It is detected as a palpable thyroid gland during a physical exam and evaluated with I131 scans; scintigraphy shows that the isotope is not taken up in an area of the gland. The overall incidence of cancer in a cold nodule is 12% to 15%, but it is higher in people younger than 40 years and in people with calcifications present on preoperative ultrasonography. [3] [4]

Anatomy

Thyroid gland tissue envelops the upper trachea just below the thyroid and cricoid cartilages that make up the larynx. The gland has an isthmus and often asymmetric right and left lobes; usually four parathyroid glands lie posteriorly. When swallowing, the thyroid may be felt to rise with the larynx—most commonly in the presence of a disease process.

Anatomy of the thyroid and parathyroid glands; drawing shows the thyroid gland at the base of the throat near the trachea. An inset shows the front and back views. The front view shows that the thyroid is shaped like a butterfly, with the right lobe and left lobe connected by a thin piece of tissue called the isthmus. The back view shows the four pea-sized parathyroid glands. The larynx is also shown.Anatomy of the thyroid and parathyroid glands.

Risk Factors

Patients with a history of radiation therapy administered in infancy or childhood for benign conditions of the head and neck (such as enlarged thymus, tonsils, or adenoids; or acne) have an increased risk of cancer and other abnormalities of the thyroid gland. In this group of patients, malignancies of the thyroid gland appear as early as 5 years after radiation therapy and may appear 20 or more years later. [5] Radiation exposure as a consequence of nuclear fallout has also been associated with a high risk of thyroid cancer, especially in children. [6] [7] [8]

Other risk factors for thyroid cancer include the following: [9]

Diagnostic and Staging Evaluation

The following tests and procedures may be used in the diagnosis and staging of thyroid cancer:

Prognostic Factors for Well-differentiated Thyroid Cancer

Age appears to be the single most important prognostic factor. [12] The prognosis for differentiated carcinoma (papillary or follicular) without extracapsular extension or vascular invasion is better for patients younger than 40 years. [12] [13] [14] [15] [16]

Patients considered at low risk according to age, metastases, extent, and size (AMES) risk criteria include women younger than 50 years and men younger than 40 years without evidence of distant metastases. The low-risk group also includes older patients with primary papillary tumors smaller than 5 cm without evidence of gross extrathyroid invasion, and older patients with follicular cancer without major capsular invasion or blood vessel invasion. [14] Using these criteria, a retrospective study of 1,019 patients showed that the 20-year survival rate was 98% for low-risk patients and 50% for high-risk patients. [14]

A retrospective surgical series of 931 previously untreated patients with differentiated thyroid cancer found that age older than 45 years, follicular histology, primary tumor larger than 4 cm (T2–T3), extrathyroid extension (T4), and distant metastases were adverse prognostic factors. [17] [18] Favorable prognostic factors included female gender, multifocality, and regional lymph node involvement. [17] Other studies, however, have shown that regional lymph node involvement had no effect [19] [20] or had an adverse effect on survival. [15] [16] [21]

The prognostic significance of lymph node status is controversial. Use of sentinel lymph node biopsy may aid in identifying patients with occult metastases who might benefit from central neck dissection. [22]

Diffuse, intense immunostaining for vascular endothelial growth factor in patients with papillary cancer has been associated with a high rate of local recurrence and distant metastases. [23] An elevated serum thyroglobulin level correlates strongly with recurrent tumor when found in patients with differentiated thyroid cancer during postoperative evaluations. [24] [25] Serum thyroglobulin levels are most sensitive when patients are hypothyroid and have elevated serum thyroid-stimulating hormone levels. [26] Expression of the tumor suppressor gene p53 has also been associated with an adverse prognosis for patients with thyroid cancer. [27]

Refer to the Clinical Features and Prognosis section of the Medullary Thyroid Cancer section and the Clinical Features and Prognosis section of the Anaplastic Thyroid Cancer section of this summary for more information about prognosis.

Related Summaries

Other PDQ summaries containing information related to thyroid cancer include the following:

References:

  1. LiVolsi VA: Pathology of thyroid disease. In: Falk SA: Thyroid Disease: Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy. Philadelphia, Pa: Lippincott-Raven, 1997, pp 127-175.
  2. American Cancer Society: Cancer Facts and Figures 2017. Atlanta, Ga: American Cancer Society, 2017. Available online. Last accessed July 13, 2017.
  3. Tennvall J, Biörklund A, Möller 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): 1405-14, 1986.
  4. Khoo ML, Asa SL, Witterick IJ, et al.: Thyroid calcification and its association with thyroid carcinoma. Head Neck 24 (7): 651-5, 2002.
  5. Carling T, Udelsman R: Thyroid tumors. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1457-72.
  6. Pacini F, Vorontsova T, Molinaro E, et al.: Prevalence of thyroid autoantibodies in children and adolescents from Belarus exposed to the Chernobyl radioactive fallout. Lancet 352 (9130): 763-6, 1998.
  7. Cardis E, Kesminiene A, Ivanov V, et al.: Risk of thyroid cancer after exposure to 131I in childhood. J Natl Cancer Inst 97 (10): 724-32, 2005.
  8. Tronko MD, Howe GR, Bogdanova TI, et al.: A cohort study of thyroid cancer and other thyroid diseases after the chornobyl accident: thyroid cancer in Ukraine detected during first screening. J Natl Cancer Inst 98 (13): 897-903, 2006.
  9. Iribarren C, Haselkorn T, Tekawa IS, et al.: Cohort study of thyroid cancer in a San Francisco Bay area population. Int J Cancer 93 (5): 745-50, 2001.
  10. American Cancer Society: Cancer Facts and Figures 2015. Atlanta, Ga: American Cancer Society, 2015. Available online. Last accessed July 13, 2017.
  11. Salvatore G, Giannini R, Faviana P, et al.: Analysis of BRAF point mutation and RET/PTC rearrangement refines the fine-needle aspiration diagnosis of papillary thyroid carcinoma. J Clin Endocrinol Metab 89 (10): 5175-80, 2004.
  12. Mazzaferri EL: Treating differentiated thyroid carcinoma: where do we draw the line? Mayo Clin Proc 66 (1): 105-11, 1991.
  13. Grant CS, Hay ID, Gough IR, et al.: Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important? Surgery 104 (6): 954-62, 1988.
  14. Sanders LE, Cady B: Differentiated thyroid cancer: reexamination of risk groups and outcome of treatment. Arch Surg 133 (4): 419-25, 1998.
  15. Staunton MD: Thyroid cancer: a multivariate analysis on influence of treatment on long-term survival. Eur J Surg Oncol 20 (6): 613-21, 1994.
  16. Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med 97 (5): 418-28, 1994.
  17. Shah JP, Loree TR, Dharker D, et al.: Prognostic factors in differentiated carcinoma of the thyroid gland. Am J Surg 164 (6): 658-61, 1992.
  18. Andersen PE, Kinsella J, Loree TR, et al.: Differentiated carcinoma of the thyroid with extrathyroidal extension. Am J Surg 170 (5): 467-70, 1995.
  19. Coburn MC, Wanebo HJ: Prognostic factors and management considerations in patients with cervical metastases of thyroid cancer. Am J Surg 164 (6): 671-6, 1992.
  20. Voutilainen PE, Multanen MM, Leppäniemi AK, et al.: Prognosis after lymph node recurrence in papillary thyroid carcinoma depends on age. Thyroid 11 (10): 953-7, 2001.
  21. Sellers M, Beenken S, Blankenship A, et al.: Prognostic significance of cervical lymph node metastases in differentiated thyroid cancer. Am J Surg 164 (6): 578-81, 1992.
  22. Cunningham DK, Yao KA, Turner RR, et al.: Sentinel lymph node biopsy for papillary thyroid cancer: 12 years of experience at a single institution. Ann Surg Oncol 17 (11): 2970-5, 2010.
  23. Lennard CM, Patel A, Wilson J, et al.: Intensity of vascular endothelial growth factor expression is associated with increased risk of recurrence and decreased disease-free survival in papillary thyroid cancer. Surgery 129 (5): 552-8, 2001.
  24. van Herle AJ, van Herle KA: Thyroglobulin in benign and malignant thyroid disease. In: Falk SA: Thyroid Disease: Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy. Philadelphia, Pa: Lippincott-Raven, 1997, pp 601-618.
  25. Ruiz-Garcia J, Ruiz de Almodóvar JM, Olea N, et al.: Thyroglobulin level as a predictive factor of tumoral recurrence in differentiated thyroid cancer. J Nucl Med 32 (3): 395-8, 1991.
  26. Duren M, Siperstein AE, Shen W, et al.: Value of stimulated serum thyroglobulin levels for detecting persistent or recurrent differentiated thyroid cancer in high- and low-risk patients. Surgery 126 (1): 13-9, 1999.
  27. Godballe C, Asschenfeldt P, Jørgensen KE, et al.: Prognostic factors in papillary and follicular thyroid carcinomas: p53 expression is a significant indicator of prognosis. Laryngoscope 108 (2): 243-9, 1998.

Cellular Classification of Thyroid Cancer

Cell type is an important determinant of prognosis in thyroid cancer. There are four main types of thyroid cancer divided into two categories for clinical management: [1]

References:

  1. LiVolsi VA: Pathology of thyroid disease. In: Falk SA: Thyroid Disease: Endocrinology, Surgery, Nuclear Medicine, and Radiotherapy. Philadelphia, Pa: Lippincott-Raven, 1997, pp 127-175.
  2. Kushchayeva Y, Duh QY, Kebebew E, et al.: Comparison of clinical characteristics at diagnosis and during follow-up in 118 patients with Hurthle cell or follicular thyroid cancer. Am J Surg 195 (4): 457-62, 2008.
  3. Mills SC, Haq M, Smellie WJ, et al.: Hürthle cell carcinoma of the thyroid: Retrospective review of 62 patients treated at the Royal Marsden Hospital between 1946 and 2003. Eur J Surg Oncol 35 (3): 230-4, 2009.

Stage Information for Thyroid Cancer

Definitions of TNM

The American Joint Committee on Cancer (AJCC) has designated staging by the primary tumor, regional lymph nodes, and distant metastasis (TNM) classification to define thyroid cancer. [1] Definitions of TNM stages for each type of thyroid cancer are described in the following sections:

References:

  1. Thyroid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 87-96.

Treatment Option Overview for Thyroid Cancer

Treatment options for thyroid cancer are described in Table 1.

Table 1. Standard Treatment Options for Thyroid Cancer

Type of thyroid cancerStage (TNM Staging Criteria)Treatment Options
Papillary and follicularStages I and II Surgery with or without RAI
 Total thyroidectomy  
 RAI  
 Lobectomy  
 Thyroid suppression therapy  
  Watchful waiting
Papillary and follicularStage III Surgery with or without postoperative RAI
   EBRT
Papillary and follicularStage IV Iodine-sensitive:
  Radiation therapy (RAI ablation therapy)
  Iodine-resistant:
  Thyroid suppression therapy
  Targeted therapy
  Surgery
  EBRT
Recurrent papillary and follicular thyroid cancer Surgery with or without postoperative RAI therapy
  Targeted therapy
  EBRT
  Chemotherapy
Medullary thyroid cancerLocalized diseaseTotal thyroidectomy
  EBRT
Locally advanced and metastatic disease Targeted therapy
  Palliative chemotherapy
Anaplastic thyroid cancer Surgery
  EBRT
  Chemotherapy
EBRT = external-beam radiation therapy; M = distant metastases; N = regional lymph nodes; RAI = radioactive iodine; T = primary tumor.

Papillary and Follicular Thyroid Cancer

Clinical Features and Prognosis

The clinical features and prognosis of differentiated thyroid tumors vary by stage.

Most papillary cancers have some follicular elements. These follicular elements may outnumber the papillary formations, but they do not change the prognosis.

Follicular adenomas, which are characterized by their lack of invasion through the capsule into the surrounding thyroid tissue, must be distinguished from follicular thyroid carcinoma. While follicular cancer has a good prognosis, it is less favorable than that of papillary carcinoma. The 10-year survival is better for patients with follicular carcinoma without vascular invasion than it is for patients with vascular invasion.

Papillary carcinomas metastasize more frequently to regional lymph nodes than to distant sites, whereas follicular carcinomas more commonly invade blood vessels and metastasize hematogenously to the lungs and to the bone rather than through the lymphatic system. When metastases occur, treatment with radioiodine is initially effective, but prognosis worsens as resistance to radioiodine ensues.

The clinical features and prognoses for papillary thyroid cancer include the following:

The clinical features and prognoses for follicular thyroid cancer include the following:

Hürthle cell carcinoma is a variant of follicular carcinoma with a similar prognosis and is treated in the same way as equivalent stage non-Hürthle cell follicular carcinoma. [1]

Stage Information for Papillary and Follicular Thyroid Cancer

Table 2. Definitions of TNM Stages for Papillary and Follicular Cancer

StageTaNbMDescriptionIllustration
Patients younger than 45 years:

Stage I papillary and follicular thyroid cancer in patients younger than 45 years; drawing shows cancer in the thyroid gland. Also shown are the larynx and trachea.

IAny T, Any N, M0TXPrimary tumor cannot be assessed.  
T0No evidence of primary tumor.   
T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.   
T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
T4bVery advanced disease.   
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.   
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).    
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IIAny T, Any N, M1TXPrimary tumor cannot be assessed.

Stage II papillary and follicular thyroid cancer in patients younger than 45 years; drawing shows other parts of the body where thyroid cancer may spread, including the lymph nodes, lung, and bone. An inset shows cancer cells spreading from the thyroid, through the blood and lymph system, to another part of the body where metastatic cancer has formed.

T0No evidence of primary tumor.   
T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.   
T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
T4bVery advanced disease.   
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.   
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).    
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M1Distant metastasis.    
Patients aged 45 years or older:
IT1, N0, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage I papillary and follicular thyroid cancer in patients 45 years and older; drawing shows cancer in the thyroid gland. The tumor is 2 centimeters or smaller. Also shown are the larynx and trachea.

N0No regional lymph node metastasis.   
M0No distant metastasis.    
IIT2, N0, M0T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.

Stage II papillary and follicular thyroid cancer in patients 45 years and older; drawing shows cancer in the thyroid gland. The tumor is larger than 2 centimeters but not larger than 4 centimeters. Also shown are the larynx and trachea.

N0No regional lymph node metastasis.   
M0No distant metastasis.    
IIIT1-3, N0-N1a, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage III papillary and follicular thyroid cancer in patients 45 years and older; drawing shows (a) cancer in the thyroid gland and the tumor is larger than 4 centimeters; (b) cancer has spread to tissues just outside the thyroid gland; and (c) cancer has spread to lymph nodes near the trachea. Also shown is the larynx.

T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes.   
M0No distant metastasis.    
IVAT1-T4a, N0-N1b, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage IVA papillary and follicular thyroid cancer in patients 45 years and older; drawing shows cancer that has spread from the thyroid gland to the larynx, the esophagus, the left recurrent laryngeal nerve, the trachea, and a lymph node on one side of the neck. Also shown is the right recurrent laryngeal nerve.

T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes.   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVBT4b, Any N, M0T4bVery advanced disease.

Stage IVB papillary and follicular thyroid cancer in patients 45 years and older; drawing shows cancer that has spread from the thyroid gland to tissue in front of the spine and has surrounded the common carotid artery and the blood vessels in the area between the lungs. Also shown are the internal jugular vein, lymph nodes, and trachea.

Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.   
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes.   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVCAny T, Any N, M1TXPrimary tumor cannot be assessed.

Stage IVC papillary and follicular thyroid cancer in patients 45 years and older; drawing show other parts of the body where thyroid cancer may spread, including the lymph nodes, lung, and bone. An inset shows cancer cells spreading from the thyroid, through the blood and lymph system, to another part of the body where metastatic cancer has formed.

T0No evidence of primary tumor.   
T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.   
T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
T4bVery advanced disease.   
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.   
N0No regional lymph node metastasis.   
N1Regional lymph node metastasis.   
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes.   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M1Distant metastasis.    
M = distant metastasis; N = regional lymph nodes; T = primary tumor.
Reprinted with permission from AJCC: Thyroid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 87-96.
aAll categories may be subdivided: (s) solitary tumor and (m) multifocal tumor (the largest determines the classification).
bRegional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes.

Standard Treatment Options for Papillary and Follicular Thyroid Cancer

Stages I and II papillary and follicular thyroid cancer

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 with the two procedures are similar, with differences in the rates of surgical complications and local recurrences. [2] [3] [4] [5] [6] [7] [8]

Standard treatment options for stages I and II papillary and follicular thyroid cancer

Standard treatment options for stages I and II papillary and follicular thyroid cancer include the following:

  1. Surgery with or without radioactive iodine (RAI).
  2. Watchful waiting. [9]

Surgery with or without radioactive iodine (RAI)

The objective of surgery is to completely remove the primary tumor, while minimizing treatment-related morbidity, and to guide postoperative treatment with RAI. The goal of RAI is to ablate the remnant thyroid tissue to improve the specificity of thyroglobulin assays, which allows the detection of persistent disease by follow-up whole-body scanning. For patients undergoing RAI, removal of all normal thyroid tissue is an important surgical objective. Additionally, for accurate long-term surveillance, RAI whole-body scanning and measurement of serum thyroglobulin are affected by residual, normal thyroid tissue, and in these situations, near total or total thyroidectomy is required. This approach facilitates follow-up thyroid scanning.

Total thyroidectomy

Total thyroidectomy is often used because of the high incidence of multicentric involvement of both lobes of the gland and the possibility of dedifferentiation of any residual tumor to the anaplastic cell type.

Evidence (total thyroidectomy):

  1. From the National Cancer Data Base (NCDB) registry of 52,173 patients, 43,227 (82.9%) underwent total thyroidectomy, and 8,946 (17.1%) underwent lobectomy. [10][Level of evidence: 3iiA]
  2. In a pattern of care study that used the NCDB registry from 1985 to 2003, 57,243 papillary thyroid cancer patients with tumors measuring 1 cm or larger underwent total thyroidectomy or lobectomy. Trends in the extent of surgery were examined for patients with papillary thyroid cancer over two decades. Logistic regression was used to identify factors that predict the use of total thyroidectomy compared with lobectomy. [11][Level of evidence: 3i]

RAI therapy

Studies have shown that a postoperative course of therapeutic (ablative) doses of radioiodine I131 results in a decreased recurrence rate among high-risk patients with papillary and follicular carcinomas. [5] RAI may be given in addition to exogenous thyroid hormone but is not considered routine. [12] RAI treatment is optimal after total thyroidectomy with minimal thyroid remnant. With a large thyroid remnant, a low thyroglobulin level cannot be achieved, which increases the chance of requiring multiple doses of RAI.

Consideration of RAI for remnant ablation is based on pathological risk features including the following:

RAI may be given with one of two methods of thyrotropin stimulation:

Administered rhTSH maintains quality of life and reduces the radiation dose delivered to the body compared with thyroid hormone withdrawal. [13] Patients presenting with papillary thyroid microcarcinomas (tumors <10 mm), which are considered to be very low risk, have an excellent prognosis when treated surgically. Additional therapy with I131 would not be expected to improve the prognosis. [14]

The role of RAI in low-risk patients is not clear because disease-free survival (DFS) or overall survival (OS) benefits have not been demonstrated.

Evidence (surgery with or without RAI):

  1. One study reviewed 1,298 patients from the French Thyroid Cancer Registry. [15] Patients were identified as having low-risk papillary or follicular cancer as they are defined by the American Thyroid Association and the European Thyroid Association criteria which include the following:

Of the 1,298 patients, 911 patients received RAI after surgery, and 387 patients did not receive RAI after surgery. The follow-up period was 10.3 years.

Long-term complications of RAI using I131 include the following:

Options for reducing the amount of radiation exposure by reducing the amount of RAI in each dose and also giving RAI in combination with rhTSH injections have been explored for low-risk thyroid cancer patients.

Evidence (thyroid hormone withdrawal or use of rhTSH with I131):

  1. A phase III, randomized, noninferiority study of patients with low-risk thyroid cancer using a comparison of two thyrotropin-stimulation methods (thyroid hormone withdrawal or use of rhTSH) and two doses of radioiodine I131 (1.1GBq [30mCi] and 3.7GBq [100mCi]) using a 2 × 2 factorial design was reviewed. [16][Level of evidence: 3iA]
  2. Another phase III, randomized, noninferiority study of patients with low-risk thyroid cancer using a comparison of two thyrotropin-stimulation methods (thyroid hormone withdrawal or use of rhTSH) and two doses of radioiodine I131 (1.1GBq [30mCi] and 3.7GBq [100mCi]) using a 2 × 2 factorial design was reviewed. The inclusion criteria consisted of a low-risk, homogeneous cohort in which all of the patients underwent total thyroidectomy, and had pathological TNM stage pT1 (≤1 cm) and N1 or NX, pT1 (>1–2cm) and any N, or pT2, N0 without thyroid capsule extension/distant metastases. [17][Level of evidence: 3iA]

Neither study assessed the effect of low-dose RAI on long-term recurrences or survival. The studies also did not address whether RAI could be safely omitted in specific low-risk groups.

Lobectomy

Thyroid lobectomy alone may be sufficient treatment for small (<1 cm), low-risk, unifocal, intrathyroidal papillary carcinomas in the absence of previous head and neck irradiation or radiologically or clinically involved cervical nodal metastases. This procedure is associated with a lower incidence of complications, but approximately 5% to 10% of patients will have a recurrence in the thyroid after a lobectomy. [18]

Abnormal regional lymph nodes are biopsied at the time of surgery. Recognized involved nodes are removed at initial surgery, but selective node removal can be performed, and radical neck dissection is usually not required. This results in a decreased recurrence rate but has not been shown to improve survival. Follicular thyroid cancer commonly metastasizes to lungs and bone. When a remnant lobe remains, use of I131 as ablative therapy is compromised because the radioiodine will be preferentially taken up by the remnant normal tissue rather than by the tumor.

Thyroid suppression therapy

Patients receive postoperative treatment with exogenous thyroid hormone in doses sufficient to suppress thyroid-stimulating hormone (TSH) after a thyroid lobectomy. Studies have shown a decreased incidence of recurrence when TSH is suppressed.

Stage III papillary and follicular thyroid cancer

Standard treatment options for stage III papillary and follicular thyroid cancer include the following:

  1. Total thyroidectomy and removal of involved lymph nodes or other sites of extrathyroid disease.
  2. RAI therapy (I131 ablation) after total thyroidectomy if the tumor demonstrates uptake of this isotope. [12]
  3. External-beam radiation therapy (EBRT) if I131 uptake is minimal. [19]

Stage IV papillary and follicular thyroid cancer

The most common sites of metastases are lymph nodes, lungs, and bone. Treatment of lymph node metastases alone is often curative. Treatment of distant metastases is usually not curative but may produce significant palliation.

Standard treatment options for iodine-sensitive thyroid cancer

Standard treatment options for iodine-sensitive thyroid cancer include the following:

  1. RAI ablation therapy: Metastases that demonstrate uptake of this isotope may be ablated by therapeutic doses of I131.

Standard treatment options for iodine-resistant thyroid cancer

Standard treatment options for iodine-resistant thyroid cancer include the following:

  1. Thyroid suppression therapy.
  2. Targeted therapy.
  3. Surgery.
  4. External-beam radiation therapy (EBRT).

Thyroid suppression therapy

TSH suppression with thyroxine is effective in many lesions that are not sensitive to I131.

Targeted therapy

Sorafenib

Sorafenib is an orally active, multityrosine kinase inhibitor.

Evidence (sorafenib):

  1. A phase III randomized, double-blind, placebo-controlled study (DECISION [NCT00984282]) evaluated the activity of sorafenib in patients with progressive, iodine-refractory differentiated thyroid cancer. [20] In the trial, 417 patients with locally advanced or metastatic radioactive iodine−refractory thyroid cancer (papillary, follicular [including Hürthle cell], and poorly differentiated, not anaplastic, tumors, defined as beyond well-differentiated tumors or those well-differentiated tumors that become resistant to radioiodine treatment) whose disease had progressed within the past 14 months were randomly assigned to receive sorafenib (400 mg bid) or placebo. Patients who received previous chemotherapy, thalidomide, or targeted therapy were excluded. [20][Level of evidence: 1iDiii]

Lenvatinib

Lenvatinib is an orally active, multitargeted tyrosine kinase inhibitor.

Evidence (lenvatinib):

  1. A phase III, randomized, double-blind, placebo-controlled study (SELECT [NCT01321554]) evaluated the activity of lenvatinib in patients with progressive, iodine-refractory, differentiated thyroid cancer. [21] In this trial, 261 patients were randomly assigned to receive lenvatinib (24 mg per day), and 131 patients were randomly assigned to receive placebo. Eligible patients had differentiated thyroid cancer (including papillary, follicular, poorly differentiated, and Hürthle cell carcinomas), radioactive iodine−refractory disease, and evidence of radiological progression within the previous 13 months. Upon disease progression, patients in the placebo group could receive open-label lenvatinib. [21][Level of evidence: 1iDiii]
    1. The primary endpoint was PFS, and secondary endpoints were OS, response rate, and safety.
    2. The median PFS in the lenvatinib group was 18.3 months versus 3.6 months in the placebo group (HR for progression or death, 0.21; 99% CI, 0.14–0.31; P < .001). A PFS difference was observed in patients with all histologic types of thyroid cancer enrolled in this trial.
    3. There was no significant difference in OS between the two groups (HR for death, 0.73; 95% CI, 0.50–1.07; P = .10), even with the crossover design of the study.
    4. Objective response rate was 64.8% in the lenvatinib group versus 1.5% in the placebo group (odds ratio [OR], 28.87; 95% CI, 12.46–66.86; P < .001).
    5. Treatment-related AEs (all grades) occurred in 97.3% of patients in the lenvatinib group and 59.5% of patients in the placebo group.
      • Grade 3 or higher AEs were observed in 75.9% of patients receiving lenvatinib and 9.9% of patients receiving placebo.
      • The most common AEs in the lenvatinib group were hypertension (67.8%), diarrhea (59.4%), fatigue (59%), decreased appetite (50.2%), decreased weight (46.4%), and nausea (41%).
      • Discontinuation of study drug due to AEs occurred in 14.2% of patients receiving lenvatinib and 2.3% of patients receiving placebo.
      • In the lenvatinib group, 6 of 20 deaths occurring during the treatment period were considered drug related.

Surgery

Resection of limited metastases, especially symptomatic metastases, should be considered when the tumor has no uptake of I131.

External-beam radiation therapy (EBRT)

EBRT is considered for patients with localized lesions that are unresponsive to I131. [19]

Treatment options under clinical evaluation for stage IV papillary and follicular thyroid cancer

Patients unresponsive to I131 should also be considered candidates for clinical trials testing new approaches to this disease.

Recurrent papillary and follicular thyroid cancer

Approximately 10% to 30% of patients thought to be disease free after initial treatment will develop recurrence and/or metastases. Of these patients, approximately 80% develop recurrence with disease in the neck alone, and 20% develop recurrence with distant metastases. The most common site of distant metastasis is the lung. In a single series of 289 patients who developed recurrences after initial surgery, 16% died of cancer at a median time of 5 years after recurrence. [5]

The prognosis for patients with clinically detectable recurrences is generally poor, regardless of cell type. [26] Patients who recur with local or regional tumor detected only by I131 scan have a better prognosis. [27]

The selection of further treatment depends on many factors, including the following:

Patients treated for differentiated thyroid cancer are followed carefully with physical examinations, serum quantitative thyroglobulin levels, and radiologic studies based on individual risk for recurrent disease. [28]

Standard treatment options for recurrent papillary and follicular thyroid cancer

Standard treatment options for recurrent papillary and follicular thyroid cancer include the following:

  1. Surgery with or without postoperative radioactive iodine therapy (RAI).
  2. Targeted therapy.
  3. EBRT.
  4. Chemotherapy.

Surgery with or without postoperative RAI therapy

Surgery with or without I131 ablation can be useful in controlling local recurrences, regional node metastases, or occasionally, metastases at other localized sites. [29] Approximately 50% of the patients who undergo surgery for recurrent tumors can be rendered free of disease with a second operation. [26] Local and regional recurrences detected by I131 scan and not clinically apparent can be treated with I131 ablation and have an excellent prognosis. [30]

Up to 25% of recurrences and metastases from well-differentiated thyroid cancer may not show I131 uptake. For these patients, other imaging techniques shown to be of value include the following: [31]

Patients unresponsive to I131 should also be considered candidates for clinical trials testing new approaches to treating this disease.

Targeted therapy

Sorafenib

Sorafenib is an orally active, multityrosine kinase inhibitor. It has been approved by the U.S. Food and Drug Administration as a treatment option when recurrent disease does not concentrate I131 or disease recurs after I131 ablation.

Evidence (sorafenib):

  1. A phase III randomized, double-blind, placebo-controlled study (DECISION [NCT00984282]) evaluated the activity of sorafenib in patients with progressive, iodine-refractory differentiated thyroid cancer. [20] In the trial, 417 patients with locally advanced or metastatic radioactive iodine–refractory thyroid cancer (papillary, follicular [including Hürthle cell], and poorly differentiated tumors) whose disease had progressed within the past 14 months were randomly assigned to receive sorafenib (400 mg bid) or placebo. Patients who received previous chemotherapy, thalidomide, or targeted therapy were excluded. [20][Level of evidence: 1iDiii]

Lenvatinib

Lenvatinib is an orally active, multitargeted tyrosine kinase inhibitor.

Evidence (lenvatinib):

  1. A phase III, randomized, double-blind, placebo-controlled study (SELECT [NCT01321554]) evaluated the activity of lenvatinib in patients with progressive, iodine-refractory, differentiated thyroid cancer. [21] In this trial, 261 patients were randomly assigned to receive lenvatinib (24 mg per day), and 131 patients were randomly assigned to receive placebo. Eligible patients had differentiated thyroid cancer (including papillary, follicular, poorly differentiated, and Hürthle cell carcinomas), radioactive iodine–refractory disease, and evidence of radiological progression within the previous 13 months. Upon disease progression, patients in the placebo group could receive open-label lenvatinib. [21][Level of evidence: 1iDiii]
    1. The primary endpoint was PFS, and secondary endpoints were OS, response rate, and safety.
    2. The median PFS in the lenvatinib group was 18.3 months versus 3.6 months in the placebo group (HR for progression or death, 0.21; 99% CI, 0.14–0.31; P < .001). A PFS difference was observed in patients with all histologic types of thyroid cancer enrolled in this trial.
    3. There was no significant difference in OS between the two groups (HR for death, 0.73; 95% CI, 0.50–1.07; P = .10), even with the crossover design of the study.
    4. Objective response rate was 64.8% in the lenvatinib group versus 1.5% in the placebo group (OR, 28.87; 95% CI, 12.46–66.86; P < .001).
    5. Treatment-related AEs (all grades) occurred in 97.3% of patients in the lenvatinib group and 59.5% of patients in the placebo group.
      • Grade 3 or higher AEs were observed in 75.9% of patients receiving lenvatinib and 9.9% of patients receiving placebo.
      • The most frequent AEs in the lenvatinib group were hypertension (67.8%), diarrhea (59.4%), fatigue (59%), decreased appetite (50.2%), decreased weight (46.4%), and nausea (41%).
      • Discontinuation of study drug due to AEs occurred in 14.2% of patients receiving lenvatinib and 2.3% of patients receiving placebo.
      • In the lenvatinib group, 6 of 20 deaths occurring during the treatment period were considered to be drug-related.

EBRT

EBRT or intraoperative radiation therapy can be useful in controlling symptoms related to local tumor recurrences. [32]

Chemotherapy

Systemic chemotherapy can be considered. Chemotherapy has been reported to produce occasional objective responses, usually of short duration. [24] [27]

Treatment options under clinical evaluation for recurrent papillary and follicular thyroid cancer

Clinical trials evaluating new treatment approaches to this disease should be considered for these patients. Oral inhibitors of VEGF receptors are under clinical evaluation. [25][Level of evidence: 2Dii]

Current Clinical Trials

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage I papillary thyroid cancer, stage I follicular thyroid cancer, stage II papillary thyroid cancer, stage II follicular thyroid cancer, stage III papillary thyroid cancer, stage III follicular thyroid cancer, stage IV papillary thyroid cancer, stage IV follicular thyroid cancer and recurrent thyroid cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

References:

  1. Haigh PI, Urbach DR: The treatment and prognosis of Hürthle cell follicular thyroid carcinoma compared with its non-Hürthle cell counterpart. Surgery 138 (6): 1152-7; discussion 1157-8, 2005.
  2. Carling T, Udelsman R: Thyroid tumors. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1457-72.
  3. Grant CS, Hay ID, Gough IR, et al.: Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important? Surgery 104 (6): 954-62, 1988.
  4. Cady B, Rossi R: An expanded view of risk-group definition in differentiated thyroid carcinoma. Surgery 104 (6): 947-53, 1988.
  5. Mazzaferri EL, Jhiang SM: Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med 97 (5): 418-28, 1994.
  6. Staunton MD: Thyroid cancer: a multivariate analysis on influence of treatment on long-term survival. Eur J Surg Oncol 20 (6): 613-21, 1994.
  7. Tollefsen HR, Shah JP, Huvos AG: Follicular carcinoma of the thyroid. Am J Surg 126 (4): 523-8, 1973.
  8. Edis AJ: Surgical treatment for thyroid cancer. Surg Clin North Am 57 (3): 533-42, 1977.
  9. Vaccarella S, Franceschi S, Bray F, et al.: Worldwide Thyroid-Cancer Epidemic? The Increasing Impact of Overdiagnosis. N Engl J Med 375 (7): 614-7, 2016.
  10. Bilimoria KY, Bentrem DJ, Ko CY, et al.: Extent of surgery affects survival for papillary thyroid cancer. Ann Surg 246 (3): 375-81; discussion 381-4, 2007.
  11. Bilimoria KY, Bentrem DJ, Linn JG, et al.: Utilization of total thyroidectomy for papillary thyroid cancer in the United States. Surgery 142 (6): 906-13; discussion 913.e1-2, 2007.
  12. 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. J Nucl Med 25 (12): 1287-93, 1984.
  13. Hänscheid H, Lassmann M, Luster M, et al.: Iodine biokinetics and dosimetry in radioiodine therapy of thyroid cancer: procedures and results of a prospective international controlled study of ablation after rhTSH or hormone withdrawal. J Nucl Med 47 (4): 648-54, 2006.
  14. 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): 1139-46; discussion 1146-7, 1992.
  15. Schvartz C, Bonnetain F, Dabakuyo S, et al.: Impact on overall survival of radioactive iodine in low-risk differentiated thyroid cancer patients. J Clin Endocrinol Metab 97 (5): 1526-35, 2012.
  16. Schlumberger M, Catargi B, Borget I, et al.: Strategies of radioiodine ablation in patients with low-risk thyroid cancer. N Engl J Med 366 (18): 1663-73, 2012.
  17. Mallick U, Harmer C, Yap B, et al.: Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer. N Engl J Med 366 (18): 1674-85, 2012.
  18. Hay ID, Grant CS, Bergstralh EJ, et al.: Unilateral total lobectomy: is it sufficient surgical treatment for patients with AMES low-risk papillary thyroid carcinoma? Surgery 124 (6): 958-64; discussion 964-6, 1998.
  19. Simpson WJ, Carruthers JS: The role of external radiation in the management of papillary and follicular thyroid cancer. Am J Surg 136 (4): 457-60, 1978.
  20. Brose MS, Nutting CM, Jarzab B, et al.: Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. Lancet 384 (9940): 319-28, 2014.
  21. Schlumberger M, Tahara M, Wirth LJ, et al.: Lenvatinib versus placebo in radioiodine-refractory thyroid cancer. N Engl J Med 372 (7): 621-30, 2015.
  22. Gottlieb JA, Hill CS Jr, Ibanez ML, et al.: Chemotherapy of thyroid cancer. An evaluation of experience with 37 patients. Cancer 30 (3): 848-53, 1972.
  23. Harada T, Nishikawa Y, Suzuki T, et al.: Bleomycin treatment for cancer of the thyroid. Am J Surg 122 (1): 53-7, 1971.
  24. 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): 2155-60, 1985.
  25. Sherman SI, Wirth LJ, Droz JP, et al.: Motesanib diphosphate in progressive differentiated thyroid cancer. N Engl J Med 359 (1): 31-42, 2008.
  26. Goretzki PE, Simon D, Frilling A, et al.: Surgical reintervention for differentiated thyroid cancer. Br J Surg 80 (8): 1009-12, 1993.
  27. De Besi P, Busnardo B, Toso S, et al.: Combined chemotherapy with bleomycin, adriamycin, and platinum in advanced thyroid cancer. J Endocrinol Invest 14 (6): 475-80, 1991.
  28. Ross DS: Long-term management of differentiated thyroid cancer. Endocrinol Metab Clin North Am 19 (3): 719-39, 1990.
  29. Pak H, Gourgiotis L, Chang WI, et al.: Role of metastasectomy in the management of thyroid carcinoma: the NIH experience. J Surg Oncol 82 (1): 10-8, 2003.
  30. Coburn M, Teates D, Wanebo HJ: Recurrent thyroid cancer. Role of surgery versus radioactive iodine (I131) Ann Surg 219 (6): 587-93; discussion 593-5, 1994.
  31. Mallin WH, Elgazzar AH, Maxon HR 3rd: Imaging modalities in the follow-up of non-iodine avid thyroid carcinoma. Am J Otolaryngol 15 (6): 417-22, 1994 Nov-Dec.
  32. Vikram B, Strong EW, Shah JP, et al.: Intraoperative radiotherapy in patients with recurrent head and neck cancer. Am J Surg 150 (4): 485-7, 1985.

Medullary Thyroid Cancer (MTC)

Sporadic and Familial MTC

MTC 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 (MEN) syndromes types 2A and 2B (MEN2A or MEN2B). In these syndromes, there is an association with pheochromocytoma of the adrenal gland and parathyroid hyperplasia.

Approximately 25% of reported cases of MTC are familial. Familial MTC syndromes include MEN2A, which is the most common, MEN2B, and familial non-MEN syndromes. (Refer to the PDQ summary on Genetics of Endocrine and Neuroendocrine Neoplasias for more information.) Any patient with a familial variant is screened for other associated endocrine tumors, particularly parathyroid hyperplasia and pheochromocytoma. Medullary carcinoma usually secretes calcitonin, a hormonal marker for the tumor, and may be detectable in blood even when the tumor is clinically occult. Determining the level of calcitonin is useful for diagnostic purposes and for following the results of treatment.

Patients with MTC (whether familial or sporadic) are tested for RET mutations, and if they are positive, family members will also be tested. Family members may be screened for calcitonin elevation and/or for the RET proto-oncogene mutation to identify other individuals at risk for developing familial MTC. Since modest elevation of calcitonin may lead to a false-positive diagnosis of medullary carcinoma, DNA testing for the RET mutation is the optimal approach. Family members who are gene carriers may choose to undergo prophylactic thyroidectomy at an early age. [1] [2]

Clinical Features and Prognosis

MTC comprises 3% to 4% of all thyroid cancers. These tumors usually present as a hard mass in the neck or thyroid, often associated with lymphadenopathy. [3] MTC can also be diagnosed by fine-needle aspiration biopsy. Cytology typically reveals hypercellular tumors with spindle-shaped cells and poor adhesion. [4] Metastases to regional lymph nodes are found in about 50% of cases.

The overall survival of patients with MTC is 86% at 5 years and 65% at 10 years.

Prognosis depends on the following: [5]

Poor prognostic factors include the following: [4] [6] [7]

Stage Information for MTC

Several staging systems have been employed to correlate extent of disease with long-term survival in MTC. The clinical staging system of the American Joint Committee on Cancer (AJCC) correlates survival to size of the primary tumor (T), presence or absence of lymph node involvement (N), and presence or absence of distant metastasis (M). Patients with the best prognosis are those who are diagnosed by provocative screening, before the appearance of palpable disease. [8]

Table 3. Definitions of TNM Stages for MTC

StageTaNbMDescriptionIllustration
IT1, N0, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage I medullary thyroid cancer; drawing shows cancer in the thyroid gland and the tumor is 2 centimeters or smaller. Also shown are the larynx and trachea.

N0No regional lymph node metastasis.    
M0No distant metastasis.    
IIT2-T3, N0, M0T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.

Stage II medullary thyroid cancer; drawing shows (a) cancer in the thyroid gland and the tumor is larger than 2 centimeters and (b) cancer has spread to tissues just outside the thyroid gland.  Also shown are the larynx and trachea.

T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
N0No regional lymph node metastasis.    
M0No distant metastasis.    
IIIT1-T3, N1a, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage III medullary thyroid cancer; drawing shows cancer that has spread to tissues just outside the thyroid gland and to lymph nodes near the trachea and larynx.

T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).   
M0No distant metastasis.    
IVAT1-T4a, N0-N1b, M0T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.

Stage IVA medullary thyroid cancer; drawing shows cancer that has spread from the thyroid gland to the larynx, the esophagus, the left recurrent laryngeal nerve, the trachea, and a lymph node on one side of the neck. Also shown is the right recurrent laryngeal nerve.

T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVBT4b, Any N, M0T4bVery advanced disease.

Stage IVB medullary thyroid cancer; drawing shows cancer that has spread from the thyroid gland to tissue in front of the spine and has surrounded the common carotid artery and the blood vessels in the area between the lungs. Also shown are the internal jugular vein, lymph nodes, and trachea.

Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.    
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVCAny T, Any N, M1TXPrimary tumor cannot be assessed.

Stage IVC medullary thyroid cancer; drawing shows other parts of the body where thyroid cancer may spread, including the lymph nodes, lung, and bone. An inset shows cancer cells spreading from the thyroid, through the blood and lymph system, to another part of the body where metastatic cancer has formed.

T0No evidence of primary tumor.    
T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.    
T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
T4bVery advanced disease.    
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.    
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).   
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M1Distant metastasis.    
M = distant metastasis; N = regional lymph nodes; T = primary tumor.
Reprinted with permission from AJCC: Thyroid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 87-96.
aAll categories may be subdivided: (s) solitary tumor and (m) multifocal tumor (the largest determines the classification).
bRegional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes.

Standard Treatment Options for MTC

Localized disease

Standard treatment options for localized MTC include the following:

  1. Total thyroidectomy.
  2. External-beam radiation therapy (EBRT).

Radioactive iodine has no place in the treatment of patients with MTC.

Total thyroidectomy

Patients with MTC are treated with a total thyroidectomy unless there is evidence of distant metastasis. In patients with clinically palpable MTC, the incidence of microscopically positive nodes is more than 75%. Routine central and bilateral modified neck dissections are generally done. [9] When cancer is confined to the thyroid gland, the prognosis is excellent.

EBRT

EBRT has been used for palliation of locally recurrent tumors without evidence that it provides any survival advantage. [10]

Locally advanced and metastatic disease

Standard treatment options for locally advanced and metastatic MTC include the following:

  1. Targeted therapy.
  2. Palliative chemotherapy.

Targeted therapy

Vandetanib

Vandetanib is an oral inhibitor of rearranged during transfection (RET) receptor kinase, vascular endothelial growth-factor receptor (VEGFR), and epidermal growth-factor receptor.

Evidence (vandetanib):

  1. Vandetanib has been evaluated in a placebo-controlled, prospective trial (NCT00410761) in 331 patients with locally advanced and metastatic disease with a 2:1 ratio in assignment to the study drug. [11][Level of evidence: 1iiDiii]

Cabozantinib

Cabozantinib is an oral tyrosine kinase inhibitor of RET receptor kinase, hepatocyte growth factor receptor (MET), and VEGFR-2.

Evidence (cabozantinib):

  1. Cabozantinib has been evaluated in a randomized, double-blind, placebo-controlled, phase III trial (EXAM [NCT00704730]) in 330 patients with metastatic MTC and radiographic progression of disease. Patient were randomly assigned in a 2:1 ratio to receive cabozantinib (140 mg per day) or placebo. Patients receiving placebo were not permitted to cross over to cabozantinib. [12][Level of evidence: 1iDiii]

Palliative chemotherapy

Palliative chemotherapy has been reported to produce occasional responses in patients with metastatic disease. [13] [14] [15] [16] No single drug regimen can be considered standard. Some patients with distant metastases will experience prolonged survival and can be managed expectantly until they become symptomatic.

Current Clinical Trials

Check the list of NCI-supported cancer clinical trials that are now accepting patients with medullary thyroid cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

References:

  1. Lips CJ, Landsvater RM, Höppener JW, et al.: Clinical screening as compared with DNA analysis in families with multiple endocrine neoplasia type 2A. N Engl J Med 331 (13): 828-35, 1994.
  2. 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): 257-63; discussion 263-4, 1995.
  3. Soh EY, Clark OH: Surgical considerations and approach to thyroid cancer. Endocrinol Metab Clin North Am 25 (1): 115-39, 1996.
  4. Giuffrida D, Gharib H: Current diagnosis and management of medullary thyroid carcinoma. Ann Oncol 9 (7): 695-701, 1998.
  5. Carling T, Udelsman R: Thyroid tumors. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1457-72.
  6. 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 (Baltimore) 63 (6): 319-42, 1984.
  7. Bergholm U, Bergström R, Ekbom A: Long-term follow-up of patients with medullary carcinoma of the thyroid. Cancer 79 (1): 132-8, 1997.
  8. Colson YL, Carty SE: Medullary thyroid carcinoma. Am J Otolaryngol 14 (2): 73-81, 1993 Mar-Apr.
  9. Moley JF, DeBenedetti MK: Patterns of nodal metastases in palpable medullary thyroid carcinoma: recommendations for extent of node dissection. Ann Surg 229 (6): 880-7; discussion 887-8, 1999.
  10. Brierley JD, Tsang RW: External radiation therapy in the treatment of thyroid malignancy. Endocrinol Metab Clin North Am 25 (1): 141-57, 1996.
  11. Wells SA Jr, Robinson BG, Gagel RF, et al.: Vandetanib in patients with locally advanced or metastatic medullary thyroid cancer: a randomized, double-blind phase III trial. J Clin Oncol 30 (2): 134-41, 2012.
  12. Elisei R, Schlumberger MJ, Müller SP, et al.: Cabozantinib in progressive medullary thyroid cancer. J Clin Oncol 31 (29): 3639-46, 2013.
  13. 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): 2155-60, 1985.
  14. De Besi P, Busnardo B, Toso S, et al.: Combined chemotherapy with bleomycin, adriamycin, and platinum in advanced thyroid cancer. J Endocrinol Invest 14 (6): 475-80, 1991.
  15. Wu LT, Averbuch SD, Ball DW, et al.: Treatment of advanced medullary thyroid carcinoma with a combination of cyclophosphamide, vincristine, and dacarbazine. Cancer 73 (2): 432-6, 1994.
  16. Orlandi F, Caraci P, Berruti A, et al.: Chemotherapy with dacarbazine and 5-fluorouracil in advanced medullary thyroid cancer. Ann Oncol 5 (8): 763-5, 1994.

Anaplastic Thyroid Cancer

Clinical Features and Prognosis

Undifferentiated (anaplastic) carcinomas 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 carcinomas 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. [1]

Five-year survival with this tumor is poor. Death is usually from uncontrolled local cancer in the neck, usually within months of diagnosis.

Stage Information for Anaplastic Thyroid Cancer

All patients with anaplastic thyroid cancer are considered to have stage IV disease.

Table 4. Definitions of TNM Stages for Anaplastic Thyroid Cancer

StageTaNbMDescriptionIllustration
IVAT4a, Any N, M0T4aModerately advanced disease.

Stage IVA anaplastic thyroid cancer; drawing shows cancer in the thyroid gland. The lymph nodes are also shown.

Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
NXRegional lymph nodes cannot be assessed.    
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).    
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVBT4b, Any N, M0T4bVery advanced disease.

Stage IVB anaplastic thyroid cancer; drawing shows cancer that has spread to tissue just outside the thyroid gland. The lymph nodes are also shown.

Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
NXRegional lymph nodes cannot be assessed.    
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).    
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M0No distant metastasis.    
IVCAny T, Any N, M1TXPrimary tumor cannot be assessed.

Stage IVC anaplastic thyroid cancer; drawing shows other parts of the body where thyroid cancer may spread, including the lymph nodes, lung, and bone. An inset shows cancer cells spreading from the thyroid, through the blood and lymph system, to another part of the body where metastatic cancer has formed.

T0No evidence of primary tumor.    
T1Tumor ≤2 cm in greatest dimension, limited to the thyroid.    
T1aTumor ≤1 cm, limited to the thyroid.    
T1bTumor >1 cm but ≤2 cm in greatest dimension, limited to the thyroid.    
T2Tumor >2 cm but ≤4 cm in greatest dimension, limited to the thyroid.    
T3Tumor >4 cm in greatest dimension, limited to the thyroid; or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues).    
T4aModerately advanced disease.    
Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.     
T4bVery advanced disease.    
Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessels.     
cT4aIntrathyroidal anaplastic carcinoma.   
cT4bAnaplastic carcinoma with gross extrathyroid extension.    
NXRegional lymph nodes cannot be assessed.    
N0No regional lymph node metastasis.    
N1Regional lymph node metastasis.    
N1aMetastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes).    
N1bMetastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII).    
M1Distant metastasis.    
M = distant metastasis; N = regional lymph nodes; T = primary tumor.
Reprinted with permission from AJCC: Thyroid. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 87-96.
aAll categories may be subdivided: (s) solitary tumor and (m) multifocal tumor (the largest determines the classification).
bRegional lymph nodes are the central compartment, lateral cervical, and upper mediastinal lymph nodes.
cAll anaplastic carcinomas are considered T4 tumors.

Standard Treatment Options for Anaplastic Thyroid Cancer

Standard treatment options for anaplastic thyroid cancer include the following:

  1. Surgery.
  2. External-beam radiation therapy (EBRT).
  3. Chemotherapy.

Surgery

If the disease is confined to the local area, which is rare, total thyroidectomy is warranted to reduce symptoms caused by the tumor mass. [2] [3]Tracheostomy is frequently necessary.

EBRT

EBRT may be used in patients who are not surgical candidates or whose tumor cannot be surgically excised.

Chemotherapy

Anaplastic thyroid cancer is not responsive to I131 therapy. Treatment with individual anticancer drugs has been reported to produce partial remissions in some patients. Approximately 30% of patients achieve a partial remission with doxorubicin. [4] The combination of doxorubicin plus cisplatin appears to be more active than doxorubicin alone and has been reported to produce more complete responses. [5]

The combination of chemotherapy plus radiation therapy in patients after complete resection may provide prolonged survival but has not been compared with any one modality alone. [6] [7]

Current Clinical Trials

Check the list of NCI-supported cancer clinical trials that are now accepting patients with anaplastic thyroid cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI website.

References:

  1. Neff RL, Farrar WB, Kloos RT, et al.: Anaplastic thyroid cancer. Endocrinol Metab Clin North Am 37 (2): 525-38, xi, 2008.
  2. Goldman JM, Goren EN, Cohen MH, et al.: Anaplastic thyroid carcinoma: long-term survival after radical surgery. J Surg Oncol 14 (4): 389-94, 1980.
  3. Aldinger KA, Samaan NA, Ibanez M, et al.: Anaplastic carcinoma of the thyroid: a review of 84 cases of spindle and giant cell carcinoma of the thyroid. Cancer 41 (6): 2267-75, 1978.
  4. Carling T, Udelsman R: Thyroid tumors. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1457-72.
  5. 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): 2155-60, 1985.
  6. Haigh PI, Ituarte PH, Wu HS, et al.: Completely resected anaplastic thyroid carcinoma combined with adjuvant chemotherapy and irradiation is associated with prolonged survival. Cancer 91 (12): 2335-42, 2001.
  7. De Crevoisier R, Baudin E, Bachelot A, et al.: Combined treatment of anaplastic thyroid carcinoma with surgery, chemotherapy, and hyperfractionated accelerated external radiotherapy. Int J Radiat Oncol Biol Phys 60 (4): 1137-43, 2004.

Changes to This Summary (05/12/2017)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information About Thyroid Cancer

Updated statistics with estimated new cases and deaths for 2017 (cited American Cancer Society as reference 2).

Treatment Option Overview for Thyroid Cancer

Revised Table 1 to add targeted therapy as an additional treatment option for locally advanced and metastatic medullary thyroid cancer (MTC).

Papillary and Follicular Thyroid Cancer

Revised Table 2 to add staging images.

Added Lenvatinib as a new subsection under stage IV disease.

Added Lenvatinib as a new subsection under recurrent disease.

MTC

Revised Table 3 to add staging images.

Added Cabozantinib as a new subsection.

Anaplastic Thyroid Cancer

Revised Table 4 to add staging images.

Editorial changes were made to this section.

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of thyroid cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

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Board members review recently published articles each month to determine whether an article should:

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Thyroid Cancer Treatment are:

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Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

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The preferred citation for this PDQ summary is:

PDQ® Adult Treatment Editorial Board. PDQ Thyroid Cancer Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/thyroid/hp/thyroid-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389164]

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Date last modified: 2017-05-12