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Advanced Thyroid Cancer

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If an adult in your life has advanced thyroid cancer, you may want to learn more about it. This page has information about thyroid cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease of unhealthy cells. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they don’t allow our normal cells to work properly. There are many different types of cancer that can grow anywhere in the body.

Thyroid cancers are very rare, but they are being diagnosed more commonly in recent years. The rate of thyroid cancer was 11.6 per 100,000 men and women per year. Thyroid cancer is nearly three times more common in women than men. There has been an annual 7 percent increase in the number of thyroid cancers diagnosed each year between 1997 to 2009.1 SEER Fast Facts. http://seer.cancer.gov/statfacts/html/thyro.html, Accessed February 2013. This increase may be because of some unknown cause or simply because doctors are finding more early stage thyroid cancers since more doctors are using ultrasound.

Almost all thyroid cancers are differentiated tumors (papillary, follicular or Hurthle cell carcinoma). Other thyroid cancers such as medullary or anaplastic, though rare, are more likely to be aggressive and have a much poorer outcome.

A thyroid cancer can be considered advanced if:

  • The type of thyroid cancer is known to behave aggressively (e.g., poorly differentiated thyroid cancer, medullary thyroid cancer).
  • The cancer in the thyroid is behaving aggressively (e.g., has spread outside the thyroid gland or paralyzed a vocal cord).
  • The cancer has spread to the neck or other parts of the body (metastatic thyroid cancer).

In this section, we are going to discuss advanced thyroid cancer. More information on thyroid nodules and all stages of thyroid cancer can be found at Thyroid Cancer Care Collaborative.

Your loved one may have noticed a lump or swelling in or around his or her neck and then went to the doctor to get it checked. Not every lump or bump is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome can be.

Understanding the anatomy

To understand advanced thyroid cancer, you need a basic understanding of the anatomy (parts) of the head and neck.

This illustration shows different parts of the neck, where the thyroid gland is located.

33_front_larynx

The thyroid gland sits in the midline of the neck, just beneath the skin and a few layers of thin muscles. This gland secretes a hormone important in regulating many functions of the body. The thyroid gland has a right and left lobe, as well as an isthmus. The thyroid gland is made of cells that take up iodine and produce a hormone called thyroid hormone. The thyroid hormone is stored within the gland. Another type of cell in the thyroid gland is called parafollicular cells (or C-cells); these cells form a hormone called calcitonin, which helps with calcium regulation. Cancer of the C-cells results is medullary carcinoma.

Next to the thyroid gland are four parathyroid glands (two on each side). These are critical to the body to regulate levels of calcium in the blood and bones through secretion of parathyroid hormone.

72_neckanatomy

The recurrent laryngeal nerves (one on each side) run up from the vagus nerve toward the voice box (larynx) in the groove between the trachea (windpipe) and esophagus. This nerve moves the vocal cords and is responsible for speaking and control of the vocal cords during breathing.

The superior laryngeal nerves (one on each side) run downward from the vagus nerve. The external branch supplies the cricothyroid muscle and helps with changing the pitch of the voice.

The lymph nodes associated with the thyroid are mainly the central compartment lymph nodes. This includes Levels VI and VII [see illustration above]. Occasionally, thyroid cancers can spread to the lateral neck or retropharyngeal lymph nodes as well.

Causes of advanced thyroid cancer

You may want to know what caused the advanced thyroid cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

Like with most cancers, doctors can’t tell for sure what caused your loved one’s thyroid cancer. It’s a combination of genetics and the environment. Radiation exposure from prior medical treatments or natural disasters could increase the risk of developing thyroid cancer as well.

Signs and symptoms of advanced thyroid cancer

Thyroid cancers are usually found when there is a lump in the thyroid gland or when unrelated tests show a lump in the thyroid gland. Other rare signs and symptoms of thyroid cancer include:

  • A lump or bump somewhere else in the neck: A metastatic lymph node with a biopsy showing thyroid cancer is a rare way that thyroid cancer is detected.
  • Change in voice: Unlike benign tumors in the thyroid gland, thyroid cancers can invade into the nerves to the voice box (larynx) or even the trachea and esophagus. This could cause a hoarse voice.
  • Difficulty with swallowing: If thyroid tumors become very large, they could cause difficulty with swallowing.

But don’t jump to conclusions. Your loved one could have one or more of these symptoms but NOT thyroid cancer. There are several non-cancerous causes of the same symptoms. That’s why he or she needs to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have any changes in your vision or hearing?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of thyroid cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The head and neck typically require a specialist to examine them because they are not easy for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Look and feel inside the mouth
  • Feel the neck extensively and carefully to check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing advanced thyroid cancer

If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that the lesion is cancer, the doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

However, if the doctor is suspicious, he or she may choose one or more of the following actions.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment the doctor recommends.

Some surgeons also say getting some imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information. A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it. The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous. The pictures might not be clear if the patient moves or has a lot of dental work. Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour. The patient can’t have an MRI if he or she has metal implants.

For most head and neck cancers, if imaging is required, the doctor will likely start with a CT scan with contrast. Other tests might include an MRI and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the main way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during the first visit, and there is a very low chance of anything going wrong.

Thyroid cancer is often diagnosed with fine needle aspiration biopsies, the most common and easiest way to biopsy. A tiny needle is placed into the tumor, and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. A number of “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back.

Determining the type of advanced thyroid cancer

Now the doctor will need to figure out what type of cancer it is. He or she may be able to tell from biopsy results. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps in the neck are cancer. Most growths are benign (non-cancerous), and some tumors are on the borderline between benign and malignant (cancerous).

There are a few different types of thyroid cancers, as well as a few subtypes.

A thyroid cancer can be considered advanced if:

  • The type of thyroid cancer is known to behave aggressively (i.e., poorly differentiated thyroid cancer, medullary thyroid cancer)
  • The cancer in the thyroid is behaving aggressively (i.e., has spread outside the thyroid gland or paralyzed a vocal cord)
  • The cancer has spread to the neck or other parts of the body (metastatic thyroid cancer)

One of the easiest ways to separate different types of thyroid cancers is to break them into well-differentiated thyroid cancers (these resemble normal thyroid cells) and poorly differentiated thyroid cancers (these cells have grown in a way that they only partly resemble thyroid cells). Well-differentiated thyroid cancers are the most common types of thyroid cancers seen in the U.S.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. Well-differentiated thyroid cancers include most papillary carcinomas and most follicular carcinomas.

Types and subtypes of thyroid cancer include:

  • Papillary thyroid cancer: This is the most common type of thyroid cancer. The cells usually resemble thyroid cells. There are several subtypes, including:
    • Classical
    • Follicular variant
    • Tall cell variant
  • Follicular thyroid cancer: This is another (usually) well-differentiated thyroid cancer. One more aggressive subtype of follicular carcinoma is Hurthle cell carcinoma.
  • Medullary thyroid cancer: This type of cancer comes not from follicular cells in the thyroid gland but cells between the follicles called C-cells. These cells are like neuro-endocrine cells and secrete calcitonin into the body. Calcitonin helps with calcium regulation in your body. A high level of calcitonin is a sign of medullary thyroid carcinoma. This is most often associated with genetics (family history) and other hormone problems.
  • Anaplastic (undifferentiated) thyroid cancer: This is a very aggressive thyroid cancer that is poorly differentiated. It is generally considered incurable. If it is caught early and is only located within the thyroid gland, surgical removal might be an option. Otherwise, patients are usually entered into clinical trials, and some combination of chemotherapy with or without radiation is attempted.
  • Other: In very rare cases, spread of cancer from other sites can spread into the thyroid gland, or there can be a lymphoma in the thyroid gland or a squamous cell carcinoma of the thyroid.

The doctor will determine the treatment for the cancer based on the category, grade and stage of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is a pathologist’s interpretation of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be based on all of the available information. Stage is based on the physical exam, imaging studies, laboratory work and biopsies.

Like with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

T stage: the main tumor

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

78_thyroid_Tstage

Tx The primary tumor cannot be assessed.
T0 There is no evidence of the primary thyroid tumor.
T1a The tumor is 1 centimeter or less and completely within the thyroid gland.
T1b The tumor is between 1 and 2 centimeters and limited to the thyroid gland.
T2 The tumor is between 2 and 4 centimeters and limited to the thyroid gland.
T3 The tumor is more than 4 centimeters and limited to the thyroid gland OR any tumor that has minimal extension outside of the thyroid gland.
T4a Moderately advanced disease: The tumor is any size but extends beyond the thyroid capsule to invade the subcutaneous tissue, larynx, trachea, esophagus or recurrent laryngeal nerve.
T4b Very advanced disease: The tumor invades the prevertebral fascia or surrounds the carotid artery or major chest vessels.

N stage: spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to figure out the N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

79_thyroid_Nstages

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1a The cancer is in level VI nodes. This includes pretracheal, paratracheal and prelaryngeal nodes.
N1b The cancer is in lymph nodes in the lateral neck (levels I to V) or retropharyngeal nodes or level II (upper mediastinum/chest).

 

stage: spread of cancer outside the head and neck

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Staging of well-differentiated thyroid cancer is a little different than that of other cancers because age at the time of diagnosis plays a role. Patients under 45 years of age are all stage 1 unless there is evidence of spread outside of the head and neck.

Differentiated thyroid cancer:

PAPILLARY OR FOLLICULAR (DIFFERENTIATED)
Under 45 years old at diagnosis
Stage I Any T Any N M0
Stage II Any T Any N M1
PAPILLARY OR FOLLICULAR (DIFFERENTIATED)
45 years and older at diagnosis
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1a M0
T2 N1a M0
T3 N1a M0
Stage IVA T4a N0 M0
T4a N1a M0
T1 N1b M0
T2 N1b M0
T3 N1b M0
T4A N1b M0
Stage IVB T4b Any N M0
Stage IVC Any T Any N M1

Medullary thyroid cancer:

MEDULLARY THYROID CANCER
Stage I T1 N0 M0
Stage II T2 N0 M0
T3 N0 M0
Stage III T1 N1a M0
T2 N1a M0
T3 N1a M0
Stage IVA T4a N0 M0
T4a N1a M0
T1 N1b M0
T2 N1b M0
T3 N1b M0
T4a N1b M0
Stage IVB T4b Any N M0
Stage IVC Any T Any N M1

Anaplastic carcinoma:

ANAPLASTIC THYROID CANCER
Stage IVA T4a Any N M0
Stage IVB T4b Any N M0
Stage IVC Any T Any N M1

The clinical stage

Once the tests are completed, and before deciding on a treatment plan, your loved one should be given a clinical stage that looks like this:

CLINICAL STAGE
Site Thyroid
Subsite 34 years
Type Right lobe
cT Papillary
cN cT2
cM cN1a
cStage cM0

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options:

Let’s look at the types of treatments available.

Surgery

Surgical treatment for thyroid cancer is usually a thyroidectomy, which is the removal of the entire thyroid gland. Another doctor, called a pathologist, will look at what was removed to identify a more exact stage for the cancer. This report, called the pathologic stage, can help the doctor decide if radiation and/or chemotherapy are needed.

Radiation

Radiation therapy kills cancer cells with high-energy radiation such as X-rays or gamma rays. However, more often than external beam radiation, radioactive iodine is used to treat thyroid cancer. It works on the premise that thyroid cells use iodine, so when a patient drinks a radioactive form of iodine, the thyroid cells will take up the iodine and be destroyed.

Chemotherapy

Chemotherapy, or “chemo,” is rarely, if ever, used to treat thyroid cancer.

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will your loved one’s life change? These are the big questions on most people’s minds when they find out that someone they love has sinonasal cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of tumor shows how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of cure.
The Tumor Margins (edges) Some would argue that the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone have been shown to indicate a worse prognosis.

In general, it is very difficult to discuss prognosis without understanding all the details of the cancer; to give a percentage chance of cure is really difficult because cancer research looks at all sorts of different types of cancers and may include patients from long ago.

What to expect after treatment is completed

After making it through treatment, your loved one will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, your loved one should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. After making it past the first five years, your loved one can then see the doctor once a year.


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.

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