What is differentiated thyroid cancer

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BMC Cancer. Keywords: differentiated thyroid cancer, active surveillance, radioiodine I treatment, tirosine kinase inhibitors, dynamic risk stratification. The use, distribution or reproduction in other forums is permitted, provided the original author s and the copyright owner s are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Introduction The recent advances in knowledge about differentiated thyroid cancer DTC showed the need of a personalized management approach. Active Surveillance Active surveillance has been proposed as an alternative to immediate surgery to avoid overtreatment in unifocal intrathyroidal papillary microcarcinoma mPTC , without metastatic lymph nodes or aggressive cytological features 1.

Initial Treatment Surgery Accurate preoperative staging is essential to evaluate the primary tumor and the presence of lymph node metastasis to guide the extent of surgical treatment.

After Lobectomy DTC is often multifocal and bilateral and is inclined to spread to the loco-regional lymph nodes. Similarly to TTx, in patients treated by lobectomy, response to treatment can be divided into four classes 20 , 59 : 1 Excellent response: stable basal serum Tg levels related to the presence of a contralateral thyroid lobe and negative neck US; 2 Biochemical incomplete response: basal serum Tg not related to the presence of a contralateral thyroid lobe, or increasing basal serum Tg levels without evidence of structural disease; 3 Structural incomplete response: evidence of structural disease; 4 Indeterminate response: non-specific findings on neck US and doubtful trends of Tg.

Accordingly, clinicians should tailor the intensity of treatment and follow-up. On the other hand, thyroidectomy alone may be appropriate for patients with smaller tumors T1 or T2 and no evidence of suspicious lymphadenopathy. Surgery is also indicated in cases of cervical lymph node metastases and locoregional recurrence. The principal adjuvant therapy is radioactive iodine, which should be considered in patients with a high risk of locoregional recurrence or with metastatic disease. This is evidence of impaired venous outflow from the head and neck and may be associated with arterial or airway compromise from a retrosternal goiter that fills the thoracic inlet.

Invasion of tumor outside the thyroid gland can be detected on exam when a nodule does not move up and down with swallowing.

Careful exam for adenopathy of the central paratracheal area and along the jugular chain lateral neck should be performed, especially ipsilateral to the thyroid nodule. An assessment of adenopathy should be performed by an ultrasound of the central and lateral neck by professionals trained in performing this exam for thyroid cancer.

Sonographic features suggestive of metastatic nodes include loss of fatty hilum, rounded shape, cystic change, calcifications, and peripheral vascularity.

If an abnormal-appearing node is found in the central or lateral neck, a FNA biopsy should be confirmed by ultrasound-guided FNA for cytology and measurement of thyroglobulin in the needle washout. Malignant nodes need to be confirmed by aspiration, as the result directs the extent of nodal dissection during thyroidectomy.

Other anatomical imaging for metastatic disease in the neck is not routinely necessary. In particular, CT scanning with iodinated contrast should not be performed unless the trachea or mediastinum requires assessment, as the high amount of iodine in the contrast will prevent diagnostic imaging and therapy with radioactive iodine for at least 6 weeks.

If anatomic imaging is needed, either CT without contrast or MRI with gadolinium contrast can be performed. Without specific symptoms, such as bone pain or hemoptysis, additional imaging e.

The diagnosis of a DTC by FNA cytology of a thyroid nodule, an abnormal neck lymph node, or after post-surgical thyroid histology is highly accurate. Molecular markers, such as BRAF, have been suggested to help guide the extent of the initial thyroidectomy and lymph node dissection. The BRAF mutation is associated with a higher risk of extrathyroidal tumor extension, cervical adenopathy, and worse disease free survival.

Currently, there are no studies that demonstrate an improved outcome disease free survival or mortality when the extent of surgery is determined by pre-operative BRAF tumor testing. The management of thyroid cancer is individualized and must take into account risk factors for death and recurrence.

Therapy is tailored based on the combined risk factors of tumor size, histology, extrathyroidal extension, completeness of surgical resection, lymph node involvement, distant metastatic disease, and iodine avidity.

Generally, management should be directed by an endocrine physician with special expertise in thyroid cancer in conjunction with a multi-disciplinary team. The team should include a thyroid surgeon experienced in central and lateral neck dissection and a nuclear medicine physician. Generally, medical and radiation oncologists are not involved in the care of patients with DTC unless the tumor becomes non-iodine avid or radioiodine unresponsive and is locally invasive or widely metastatic.

Our recommendations are largely based on the most recent ATA guidelines. There are many unresolved questions regarding the management of thyroid cancer and the most recent guidelines recommending a reduction in the extent of surgery and radioactive iodine therapy have not all been studied prospectively. As expected, there are practice differences among various thyroid cancer centers.

This will determine the need for and extent of neck dissection. Surgery should be performed by a high-volume surgeon thyroid surgeon performing more than 50 surgeries per year , as complications of surgery including injury to the recurrent laryngeal nerve and hypoparathyroidism, are more common in patients with thyroid cancer compared to patients with benign thyroid disease.

The choice of surgery depends on several factors:. If patients with a lesion less than 1 cm is planned for surgery, a lobectomy can be performed as the initial procedure unless there is an indication to remove the contralateral lobe including contralateral nodules, history of prior head and neck irradiation, family history of thyroid carcinoma or clinically evident metastatic nodes. When there is tumor involvement of a nodal compartment confirmed by biopsy, dissection of the compartment with removal of all nodes should be performed.

Removal of individual nodes node or berry picking is not recommended. Therapeutic central or lateral neck dissection should be performed when metastatic nodes are found on pre-operative imaging and confirmed by biopsy or if detected during surgery. Prophylactic lateral neck dissection is not recommended as it does not change the risk of mortality. If the initial surgery is a lobectomy, a completion thyroidectomy should be offered to the patient if a bilateral surgery would have been the initial choice had the diagnosis of thyroid cancer been known prior to surgery.

While all patients undergoing a total or subtotal thyroidectomy will require thyroid hormone replacement, the need for thyroid hormone withdrawal in preparation for radioactive iodine therapy in certain patients may affect this. Patients who undergo a lobectomy do not need to be started on thyroid hormone replacement immediately, but may have the need in the future based on TSH levels.

Lab work at 6 weeks post op should include TSH levels and thyroglobulin levels to help determine further management. Thyroid cancer is treated with surgery and radioactive iodine. These decisions can reduce complication rates and optimize immediate and long-term quality of life for your child.

Clinicians from the Pediatric Thyroid Center will discuss the treatment plan with your child and family, and explain what to expect before, during and after surgery. The team will also detail when your child should begin a low-iodine diet, stop thyroid hormone therapy, and when radioactive iodine RAI whole body scans and treatment may begin. The type and extent of thyroid surgery recommended for your child will be based on the results of the fine-needle aspiration and preoperative evaluation.

Preoperative staging should include a complete thyroid and neck ultrasound, and may include a neck MRI or chest CT scan. PET scans are rarely needed as these findings usually do not affect the surgical approach. Surgically removing the thyroid nodule allows the pathologist to more completely evaluate the tissue to determine the appearance and behavior of the cells.

If there are indeterminate nodules in both sides of the thyroid gland — or if the patient has an increased risk of thyroid cancer based on personal or family history — complete removal of the thyroid gland is recommended. This procedure is called a total thyroidectomy.

The two most common risks of thyroid surgery include damage to the parathyroid glands or the recurrent laryngeal nerves, structures that are directly attached to the thyroid gland. The risks of thyroid surgery can be decreased by having the operation performed by an experienced surgical team that completed at least 30 thyroid surgeries per year.

The permanent complication rate for thyroid surgery patients at CHOP is less than 2 percent — significantly lower than the national average.

Some patients who undergo a lobectomy may be able to go home the same day as surgery. The majority of patients will need to remain in the Hospital for two to three days after a thyroidectomy. This allows your child time to recover, ensure their pain is under control, and monitor for any potential side effects of surgery such as low calcium levels or RLN damage. In most cases, surgical pain usually goes away within the first few days and most return to school within four to five days, and full activity within two weeks.

The surgical scar is usually centimeters in length and located in a skin fold to make it less noticeable. Absorbable sutures stitches and steri-strips are used so there is no need to have stitches removed.

Six to 12 weeks after surgery, patients should be re-evaluated by an experienced endocrinologist to assess if there is any lingering evidence of cancer cells, and determine whether the child would benefit from additional therapy, specifically radioactive iodine. While all patients will receive thyroid hormone replacement therapy, not all should receive — or would benefit from — radioactive iodine therapy RAI.

RAI destroys any remaining thyroid cells after surgery. For patients with a low likelihood of developing persistent thyroid cancer, the risks of RAI may outweigh the benefits. Short-term risks of RAI include inflammation of the salivary glands, dry mouth and increased cavities.

Long-term risks can include secondary malignancies such as leukemia, salivary gland cancer and others. The greater the dosage and frequency of RAI, the higher the potential risks. Based on the ATA guidelines, post-surgical patients are examined and their thyroid levels are evaluated to determine if they are at low, intermediate or high risk of cancer recurrence or metastasis cancer spreading.

RAI is not recommended for patients are low risk. Only patients at intermediate or high risk should be considered for radioactive iodine therapy. These patients should be regularly monitored to determine the best time to start and stop treatment, as well as to assess any side effects of the therapy.

Similarly, radioactive iodine therapy should not be used for patients who received a lobectomy half of their thyroid removed. If thyroid cancer does spread to the other thyroid lobe, surgery to remove the second lobe would be recommended before RAI is considered.