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Advanced Thyroid Cancer

Deciding on a Treatment Plan

Your doctors will typically use NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines®) for Thyroid Carcinoma  and the American Thyroid Association (ATA) Clinical Practice Guidelines to decide on the appropriate treatment course.4, Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Thyroid Carcinoma V.2.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed July 24, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.5Cooper, D.S., G. M. Doherty, et al. (2009). “Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer.” Thyroid 19(11): 1167-1214. If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Preoperative Evaluation

  • A full history and physical examination
  • A needle biopsy to confirm a diagnosis of cancer
  • Imaging of the thyroid and the neck
  • Measurement of thyroid stimulating hormone
  • Consider a chest x-ray
  • Consider assessing vocal cord mobility
  • Preoperative medical clearance and optimization of medical conditions
  • Maybe an ultrasound of lateral compartments for suspicious lymph nodes

Then your doctor will recommend a course of treatment for you, depending on a number of factors. As with all thyroid carcinomas, therapeutic options include:

The treatment for thyroid cancer can get complicated, particularly since it is followed over a long time. Having a conversation with your doctor is the best way to fully understand your treatment plan.

If you have thyroid cancer, you can find a lot of information on this complicated topic in the Thyroid Cancer Care Collaborative.

Surgery

In general, most cases of confirmed thyroid cancer are treated initially with surgery; however, the extent of surgery remains controversial. Also, for anaplastic carcinoma, surgery should only be undertaken if the cancer is contained and can be resected.

Possible surgeries might include:

  • Hemithyroidectomy: This can be considered for some small cancers with no evidence of tumors in the remaining lobe. The remaining lobe should be followed closely with routine ultrasounds.
  • Total thyroidectomy: This is removal of the entire thyroid gland. This will be necessary if part of the treatment will include giving radioactive iodine, or if following certain blood levels such as thyroglobulin are important.
  • Central compartment lymph node dissection: This involves removing the lymph nodes in Level VI (or central compartment) and includes the lymph nodes next to the trachea and in front of the larynx. This might be recommended if you have known cancer in your thyroid gland, or it might only be recommended if you have enlarged lymph nodes in the area. In most cases of medullary thyroid cancer, a central compartment lymph node dissection should be done (or at least considered) by your surgeon.
  • Lateral compartment lymph node dissection: This is removal of lymph nodes in the sides of the neck. This would be done if there is known cancer spread to that area.
  • Prophylactic thyroidectomy: This involves removing the thyroid gland without a proven diagnosis of thyroid cancer. This would be considered if you have a very high chance of developing thyroid cancer in the future, usually in certain cases of a family history of medullary thyroid carcinoma.
  • Revision thyroid surgery: Re-operation in the thyroid bed or at the lymph node sites might be required if there is evidence that the cancer has recurred in any of these areas.

Radiation

Radiation for thyroid cancer comes in two main forms: external beam radiation therapy and radioactive iodine.

  • External beam radiation therapy: While standard in many cancers of the head and neck, this is not recommended very frequently for thyroid cancer. One reason is that radioactive iodine is a more targeting form of radiation that attacks only thyroid cells. External beam radiation therapy might be considered in the following circumstances:
    • You are over the age of 45 and had T4 disease (with extrathyroidal extension).
    • You have an aggressive cancer than cannot be completely resected, and it is not sensitive to radioactive iodine (either in the neck, in the thyroid bed or recurrent disease).
    • You have a metastasis that is causing significant symptoms and cannot be resected (spine, brain).
  • Radioactive iodine: The main function of iodine in your body is for thyroid cells to make thyroid hormone. Thyroid cells use essentially all of the iodine in your body, and this includes well-differentiated thyroid cancer cells. Radioactive iodine might be recommended if cancer has spread to lymph nodes in your neck, or if it is in your lungs or another part of your body. You basically take a drink or ingest a capsule of radioactive iodine. When you drink radioactive iodine (I-131), the thyroid cells will take up the iodine. Since it is radioactive iodine, the cells will stop growing. This should attack thyroid cancer cells, no matter where in the body they are located, while sparing normal tissue.

This only works in cancers that resemble normal thyroid tissue; therefore, it is not effective in medullary cancer or poorly differentiated carcinomas. Even certain types of well-differentiated thyroid cancers lack the ability to take up radioactive Iodine. Also, there are side effects to RAI of which you should be aware.

You should talk to your doctor in detail about when you might need radioactive iodine since new information is constantly coming out.

Chemotherapies and other medicines

Chemotherapy is only rarely used for thyroid cancer. In some cases of medullary thyroid cancer and poorly differentiated or anaplastic thyroid cancers, your doctor might recommend chemotherapy.

Biologic medicines might also be recommended. For example, taking levothyroxine at levels that suppress your body’s production of Thyroid Stimulating Hormone (TSH) can act to decrease the chance of recurrence. The risks and benefits need to be weighed to figure out the best thyroid suppression levels for you, and you should talk to your doctor in detail. Also, for very advanced medullary thyroid carcinoma, new biologic medications (vandetanib and cabozantinib) that block specific receptors on cancer cells are FDA approved. Finally, for differentiated thyroid cancer, there are promising studies showing biologic medications called BRAF inhibitors might be useful in treating a very select group of thyroid cancers.3 Salerno P, De Falco V, Tamburrino A, Nappi TC, Vecchio G, Schweppe RE, Bollag G, Santoro M, Salvatore G. Cytostatic activity of adenosine triphosphate-competitive kinase inhibitors in BRAF mutant thyroid carcinoma cells. J Clin Endocrinol Metab. 2010;95(1):450-455.

References

1 SEER Fast Facts. http://seer.cancer.gov/statfacts/html/thyro.html Accessed February 2013.

2 Hundahl SA, Fleming ID, Fremgen AM, et al.: A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995. Cancer. 1998;83:2638-2648.

3 Salerno P, De Falco V, Tamburrino A, Nappi TC, Vecchio G, Schweppe RE, Bollag G, Santoro M, Salvatore G. Cytostatic activity of adenosine triphosphate-competitive kinase inhibitors in BRAF mutant thyroid carcinoma cells. J Clin Endocrinol Metab. 2010;95(1):450-455.

4 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Thyroid Carcinoma V.2.2013. © National Comprehensive Cancer Network, Inc 2013. All rights reserved. Accessed July 24, 2013. To view the most recent and complete version of the guideline, go online to www.nccn.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc.

5 Cooper, D.S., G. M. Doherty, et al. (2009). “Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer.” Thyroid 19(11): 1167-1214.

6 Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.