Thyroid Cancer

Home / Ear, Nose and Throat / Neck / Thyroid Cancer

Original Author(s): Faith Protts

Last updated: December 12, 2018
Revisions: 25

Introduction
Thyroid lumps are a common presentation, seen in up to 5% of the population, however only a small proportion of them are cancerous.

There are di erent types of cancer that can a ect the thyroid gland, all of which can present with di erent features. The main types of thyroid cancer are
papillary, follicular, medullary, anaplastic, and lymphoma.

© By TeachMeSeries Ltd (2020)

Figure 1 – Anterior view of the neck, showing the anatomical position of the thyroid gland

Thyroid Cancer Subtypes

Papillary Carcinoma

This is the commonest type of thyroid cancer (75%), most commonly seen between 40-50 years and in women.

There can be multiple lesions within the gland and they are rarely encapsulated. Histologically, cells are a mixture of papillary and colloid-filled follicles,
with papillary projections and pale empty nuclei. They commonly spread via the lymphatics.

Follicular Carcinoma

Usually seen at 40-60 years and in women, the second most common thyroid malignancy (15%).

They present as focal encapsulated lesions (multifocal disease is rare), with microscopic capsular invasion*. Where metastasis occurs, it is usually via
haematogenous spread to bones and lungs.

*Hurthle cell tumours are a variant of follicular neoplasms in which oxyphil cells predominate

Medullary Carcinoma

These make up around 3% of thyroid cancers and arise in the parafollicular cells (C-cells, derived from the neural crest cells). Consequently, they produce
raised calcitonin levels and are associated (20% of cases) with MEN 2 syndrome (both 2a and 2b).

Medullary carcinoma can spread by both lymphatic and medullary routes; unfortunately nodal disease is associated with a very poor prognosis.

Anaplastic Thyroid Cancer

These rare tumours, accounting for 5% of thyroid cancers, usually present in the elderly and are very aggressive.

They tend to grow rapidly with early local invasion and often have spread by the time of presentation. Prognosis is poor and treatment is often supportive.

Lymphoma

Thyroid lymphomas are very rare, making up only 1-2% of all thyroid cancers. They usually present in people over 60 years old.

They may grow quite rapidly, with marked compressive symptoms and B-Cell symptoms.
 © Adapted from work by Nephron (1,3,4), Yale Rosen (2) [CC BY-SA 3.0], via Wikimedia Commons and Flickr

Figure 2 – Histological slides of the thyroid cancer subtypes: (1) Papillary (2) Follicular (3) Medullary (4) Anaplastic

Risk Factors
Female gender

Family history
Also includes relevant cancer syndromes (e.g. medullary subtype associated with Multiple Endocrine Neoplasia (MEN) Syndrome type IIa and IIb)

Radiation exposure in childhood

Full body radiotherapy for bone marrow transplant

Hashimoto’s disease
Predisposes to lymphoma subtype

Clinical Features
Thyroid cancers may present as a palpable lump, multiple lumps, or be found incidentally on imaging of the neck.

The red flag signs to be aware of with any neck lump that may suggest a malignancy are:

Rapid growth

Pain

Cough, hoarse voice, or stridor

Multiple enlarged cervical lymph nodes

Tethering of the lump to surrounding structures

Di erential Diagnosis
It is important to remember that most lumps or swellings of the thyroid are not malignant, however some of them may still require surgical intervention for
diagnosis or management.

Benign thyroid adenoma or thyroid cyst

Toxic multi-nodular goitre

Toxic refers to excessive productive of thyroid hormone which results in the clinical features of hyperthyroidism
 © By TeachMeSeries Ltd (2020)
Non-toxic multi-nodular goitre

Thyroglossal duct cyst* (not in the thyroid itself)

Will move superiorly as the patient sticks out their tongue

*Thyroglossal cysts, prior to any suggested removal, should be fully investigated as the as the cyst may be the
only functioning thyroid tissue that the patient has therefore would not warrant removal

Figure 3 – A thyroid neck lump

Investigations
Most patients with a neck lumps should have initial Thyroid Function Tests* (TFTs) performed. Any evidence of a toxic nodule (low TSH or raised T3 or T4,
or radio-nucleotide imaging showing a “hot” nodule), then no further investigation for malignancy will be required as overactive nodules are very rarely
malignant.

*Serum calcitonin may be useful for the diagnosis and monitoring of treatment response in medullary carcinoma.

Most cases of suspected thyroid malignancy require ultrasound thyroid scan (Fig. 4), used to assess the nodule and look for cervical lymphadenopathy.
Suspicious features on ultrasound include:

Microcalcifications

Hypoechongenicity

Irregular margin

A score will be allocated (U1-U5). U1-U2 lesions have low risk of malignancy and will not require fine needle aspiration cytology (FNAC), U3-U5 lesions
should undergo FNAC.

© By Mme Mim (Own work) [CC BY-SA 4.0], via Wikimedia Commons

Figure 4 – US Thyroid showing an Anaplastic Thyroid Malignancy

Fine Needle Aspiration Cytology (FNAC) involves passing a needle into the thyroid nodule and aspirating cells out of it. These cells will be reviewed and
the relevant score allocated (Thy1-Thy5); the TNM staging system is used for thyroid cancers once diagnosis is confirmed:

Thy1 is inconclusive and requires a further sample

Thy2 is non-malignant

Thy3 is follicular lesion and requires diagnostic hemithyroidectomy for histology to determine between follicular adenoma (benign) or carcinoma

Thy4 is suspicious and requires diagnostic hemithyroidectomy

Thy5 is malignant and requires work up for appropriate treatment

Management
Thyroid cancer should be managed by a multi-disciplinary team, including endocrinologists, histopathologists, radiologists, oncologists, and ENT
surgeons, alongside of specialist nurses and speech and language therapists.
The management varies depending on the type of cancer as well as the stage. Management options include surgical, chemotherapy, radiotherapy, and
radio-iodine therapy.

Surgical Treatment
Hemi-thyroidectomy – This involves removing half of the thyroid that contains the lesion, however is only suitable for certain tumours (e.g. small low
grade non-metastatic malignancy)

Total thyroidectomy – Most malignant disease will require a total thyroidectomy, which involves removing the whole thyroid (including the isthmus);
patients will always need to take thyroid hormone replacement following this surgery

Locally advanced disease may also require neck dissection, to remove groups of lymph nodes from the surrounding region, both to aid diagnosis and
attempt to reduce disease spread.

Complications of Thyroid Surgery

Bleeding immediately after the operation can result in a haematoma forming beneath the skin. Large haematomas can cause airway obstruction, which is an
emergency. In this situation the surgical wound must be re-opened (on the ward!) to allow drainage of the haematoma and the patient will need to go back
to theatre to stop the bleeding.

Hypocalcaemia may occur if there is damage to or removal of the parathyroid glands. After a total thyroidectomy, patients must be monitored for clinical
features of hypocalcaemia, such as paraesthesia or tetany. PTH and serum calcium levels must be checked the next day (however levels can become
significantly low within hours post-operatively)

The recurrent laryngeal nerves run close to the thyroid gland, hence care during surgery must to taken to prevent damage causing vocal cord paralysis.
Unilateral palsy will result in a hoarse voice however a bilateral paralysis can result in a life-threatening stridor and tracheostomy may be warranted.

Non-Surgical Treatment
Radioiodine therapy involves administration of a radioactive iodine solution, which is taken up preferentially by residual thyroid tissue, acting a focal
radiation targeting the malignancy (used for papillary or follicular carcinomas). Only e ective after total thyroidectomy.

External beam radiotherapy can be used as primary or adjunct therapy (curative or palliative). Chemotherapy can also be used for similar means,
classically lymphomas usually responding well to chemotherapy, and symptoms can improve within a few doses.

Prognosis
The prognosis of thyroid cancer depends on the histological subtype, the grade, and the stage of the malignancy.

For papillary cancer, prognosis is quite good with 10 year survival of 90% (this drops considerably if the tumour has spread beyond the gland)

Follicular cancer has a high 10 year survival at around 85% (haematogenous spread is a marker of poorer prognosis)

Medullary cancer also has a good prognosis, with 10 year survival dropping only below 90% when nodal or metastatic spread is seen.

For anaplastic cancer, there is a very poor prognosis with a 1 year survival of 10-20%

+
Key Points
Thyroid lumps are a common presentation however only a small proportion of them are cancerous

The main types of thyroid cancer are papillary, follicular, medullary, anaplastic, and lymphoma

Red flag signs for any thyroid lump include pain, rapid growth, a cough, hoarse voice, or stridor, lymphadenopathy, or tethering of the lump

Diagnosis is made via Ultrasound Scan followed by Fine Needle Aspiration Cytology

Management options available range from surgical to medical to palliative