Treatment for Anaplastic Thyroid Cancer

If your cancer is only in the neck, your doctor will probably recommend near-total or total thyroidectomy to reduce the symptoms caused by the cancer.

• Total thyroidectomy - The surgeon removes the entire thyroid, and sometimes nearby lymph nodes, through an incision in the neck. In some rare cases, the surgeon also takes out other tissues in the neck that have been affected by the cancer.

If you have anaplastic thyroid carcinoma, your doctor might recommend surgery to remove as much cancer as possible in the neck area. If the tumor is blocking your windpipe and making it hard for you to breathe, the doctor might perform a tracheotomy.

• Tracheotomy (tracheostomy) - The surgeon makes an opening in the trachea, or windpipe, and inserts a metal, plastic, or rubber tube to help you breathe. 

After surgery, you will be treated with thyroid hormone after surgery.

• Thyroid hormone replacement - These pills can give your body the natural thyroid hormone it can no longer make on its own. The generic name of the hormone is levothyroxine sodium. It is sold as Synthroid^®, Levoxyl^®, Levothroid^®, Unithroid^®, and other brand names.

You will probably be treated with external beam radiation therapy in addition to or instead of surgery. This treatment uses high-energy x-rays or other types of radiation to kill cancer cells. It is sometimes used to reduce the chance that the disease will come back (recur) in the neck.

• External beam radiation therapy (EBRT) - Radiation from a high-energy x-ray machine (linear accelerator) outside the body is focused on the cancer cells. Most people are treated with EBRT for a few minutes 5 days a week for a few weeks or months as an outpatient.

You might also be treated with chemotherapy. Chemotherapy drugs are used to kill cancer cells. These drugs are used to destroy cancer that is still left after surgery, slow the tumor's growth, or reduce symptoms. Chemotherapy can help control any cancer that is left in the neck. It can also treat cancer that has spread (metastasized) outside the neck. Some of the chemotherapy drugs that might be used, either alone or in combination, are:

• Adriamycin^® (doxorubicin) - Doxorubicin hydrochloride belongs to the group of chemotherapy drugs known as anthracycline antibiotics. Doxorubicin stops the growth of cancer cells, which kills them. This drug is given by a shot in a vein over about 15 minutes. The dose and how often you get the medicine depend on your size, your blood counts, how well your liver works, and the type of cancer being treated. Your blood counts will be checked before each treatment; if they are too low, your treatment will be delayed.
• Platinol^® (cisplatin) - Cisplatin is a platinum compound chemotherapy drug that acts like an alkylating agent. It stops cancer cells from growing, which kills them. Cisplatin is given by an injection into the vein over at least 1 hour. Your dose depends upon the type of cancer you have, your size, and how well your kidneys work.

This content has been reviewed and approved by Myo Thant, MD. 

Chemotherapy for Thyroid Cancer

Chemotherapy drugs are used to kill cancer cells. These drugs destroy cancer that is still left after surgery, slow the tumor's growth, or reduce symptoms.

Chemotherapy is not usually used to treat thyroid cancer. But certain chemotherapy drugs are useful in combination with external radiation beam therapy for anaplastic thyroid cancers. Chemotherapy is also used sometimes for thyroid cancers that have continued to grow after treatment with radioactive iodine or external beam radiation therapy. Some of the chemotherapy drugs that are used to treat thyroid cancer are listed below.

• Adriamycin^® (doxorubicin) - Doxorubicin hydrochloride belongs to the group of chemotherapy drugs known as anthracycline antibiotics. Doxorubicin stops the growth of cancer cells, which kills them. This drug is given by a shot in a vein over about 15 minutes. The dose and how often you get the medicine depend on your size, your blood counts, how well your liver works, and the type of cancer being treated. Your blood counts will be checked before each treatment; if they are too low, your treatment will be delayed.

• Adrucil ^® or Efudex ^® (5-fluorouracil or 5-FU) - 5-FU belongs to the group of chemotherapy drugs known as antimetabolites. 5-FU prevents cells from making DNA and RNA, which stops cells from growing. 5-FU is given as a shot in the vein over 5 to 10 minutes or 20 to 60 minutes, or continuously over 22 to 24 hours for 1 to 4 days or longer. The treatment can be repeated every week, every other week, or every 3 weeks. The dose depends on your size and blood count.

• Blenoxane ^® (bleomycin) - Bleomycin belongs to the group of chemotherapy drugs known as antibiotics. Bleomycin interferes with cell division, which destroys the cells. Bleomycin is given by a shot into a vein, either over 10 minutes or as a continuous infusion for 24 hours, or as a shot into the muscle or under the skin. The dose is based on your size.

• Cytoxan ^® (cyclophosphamide) - Cyclophosphamide belongs to a group of chemotherapy drugs known as alkylating agents. It stops cancer cells from growing, which kills them. Cyclophosphamide can be given by mouth as a pill or liquid, or by a shot into a vein. The dose depends on your size, your type of cancer, and blood count.

• DTIC-Dome ^® (dacarbazine) - Dacarbazine is a chemotherapy drug that acts like an alkylating agent. It stops cancer cells from growing, which kills them. Dacarbazine is given by a shot in a vein over 20 minutes or longer. The dose and how often you get the medicine depend on your size, your blood counts, and the type of cancer being treated.

• Oncovin ^® (vincristine) - Vincristine belongs to the group of chemotherapy drugs known as plant (vinca) alkaloids. It stops cells from dividing, which kills them. Vincristine is given by an injection in a vein over 2 to 5 minutes. The dose and how often you get the medicine depend on your weight, how well your liver is working, and the type of cancer being treated.

• Platinol^® (cisplatin) - Cisplatin is a platinum compound chemotherapy drug that acts like an alkylating agent. It stops cancer cells from growing, which kills them. Cisplatin is given by an injection into the vein over at least 1 hour. Your dose depends upon the type of cancer you have, your size, and how well your kidneys work.

• VePesid ^® or Etopophos ^® (etoposide) - Etoposide belongs to the class of chemotherapy drugs known as plant alkaloids. It stops cells from dividing, which kills them. Etoposide can be given by an injection in a vein over 30 to 60 minutes, or at higher doses over 1 to 4 hours. Etoposide can also be given by mouth as a capsule. The dose depends on your size, the type of cancer being treated, and your blood counts.

This content has been reviewed and approved by Myo Thant, MD. 

Anaplastic Thyroid Cancer Review

ANAPLASTIC THYROID CANCER 

What is Anaplastic Thyroid Carcinoma?

Anaplastic thyroid carcinoma is a rare and aggressive form of cancer of the thyroid gland.

Causes, incidence, and risk factors

Anaplastic thyroid cancer grows very rapidly and is an invasive type of thyroid cancer. It occurs most often in people over age 60 but can occur in younger people. There is no known cause for Anaplastic thyroid cancer development.

A Rare Disease:  Anaplastic Thyroid Cancer accounts for only about 1% of all thyroid cancers.

Signs and Symptoms         

•  Cough
•  Loud breathing
•  Coughing up blood
•  Difficulty swallowing
•  Hoarseness or changing voice
•  Lower neck mass, often noted to be rapidly enlarging

Diagnostic Testing         

• Thyroid function blood tests are usually normal.
• A physical examination almost always show a neck mass.
• A CT scan or MRI of the neck may show a tumor growing from the thyroid gland.
• Thyroid scan shows this mass to be "cold," meaning it does not absorb a radioactive isotope.
• Examination of the airway with a fiberoptic scope (laryngoscopy) may show a paralyzed vocal cord.
• Thyroid Mass biopsy confirms Anaplastic thyroid cancer diagnosis.

Treatment: Anaplastic Thyroid Cancer cannot be cured by surgery. For most patients, complete removal of the thyroid gland does not prolong their life. Of other treatment options available, only radiation therapy combined with chemotherapy give significant benefit. For some patients, enrolling in a clinical trial of new thyroid cancer treatments may be an option.

Expectations (prognosis): The prognosis for Anaplastic Thyroid Cancer  is very poor. Most people do not survive longer than 6 months due to the aggressive nature of this disease and lack of effective treatment options.

Complications         

• Spread of tumor within the neck
• Metastasis (spread) of cancer to other body tissues or organs
• Surgery to place a tube in the throat to help with breathing (tracheostomy) is often needed.
• Surgery to place a tube in the stomach to help with eating (gastrostomy) is often needed.

Support Groups: The stress of a terminal illness for both patient, caregiver, family and loved ones can often be eased by joining a support group of people sharing common experiences and problems.

Calling Your Doctor:  Call your health care provider if you or your loved one has persistent hoarseness, changing voice, cough, or coughing up blood not associated with throat infection or respiratory illness, has any sign of a  lump or mass in the neck.

References:

Ladenson P, Kim M. Thyroid. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: chap 244.

National Comprehensive Cancer Network. NCCN Guidelines in Oncology 2010: Thyroid Cancer. Version 1.2010.

Review Date: 02/22/2012

Diagnostic Testing for Thyroid Cancer Basics

The Following Diagnostic Tests and Procedures  that examine the thyroid, neck, and blood are used to detect (find) and diagnose thyroid cancer.

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or swelling in the neck, voice box, and lymph nodes, and anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.

• Laryngoscopy: A procedure in which the doctor checks the larynx (voice box) with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing. A thyroid tumor may press on vocal cords. The laryngoscopy is done to see if the vocal cords are moving normally.

• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormal levels of thyroid-stimulating hormone (TSH). TSH is made by the pituitary gland in the brain. It stimulates the release of thyroid hormone and controls how fast follicular thyroid cells grow. The blood may also be checked for high levels of the hormone calcitonin.

• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as calcium, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it.

• Radioactive iodine scan (RAI scan): A procedure to find areas in the body where thyroid cancer cells may be dividing quickly. Radioactive iodine (RAI) is used because only thyroid cells take up iodine. A very small amount of RAI is swallowed, travels through the blood, and collects in thyroid tissue and thyroid cancer cells anywhere in the body. Abnormal thyroid cells take up less iodine than normal thyroid tissue. Areas that do not absorb the iodine normally (cold spots) show up lighter in the picture made by the scan. Cold spots can be either benign (not cancer) or malignant, so a biopsy is done to find out if they are cancer.

• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later. This procedure can show the size of a thyroid tumor and whether it is solid or a fluid-filled cyst. Ultrasound may be used to guide a fine-needle aspiration biopsy.

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.

• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).

• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

• Fine-needle aspiration biopsy of the thyroid: The removal of thyroid tissue using a thin needle. The needle is inserted through the skin into the thyroid. Several tissue samples are removed from different parts of the thyroid. A pathologist views the tissue samples under a microscope to look for cancer cells. Because the type of thyroid cancer can be hard to diagnose, patients should ask to have biopsy samples checked by a pathologist who has experience diagnosing thyroid cancer.

• Surgical biopsy: The removal of the thyroid nodule or one lobe of the thyroid during surgery so the cells and tissues can be viewed under a microscope by a pathologist to check for signs of cancer. Because the type of thyroid cancer can be hard to diagnose, patients should ask to have biopsy samples checked by a pathologist who has experience diagnosing thyroid cancer.

MEDICAL REVIEW: 02/12/2012

What Causes Thyroid Cancer ?

 Although scientists have found that thyroid cancer is linked with a number of other conditions (described in  "What are the risk factors for thyroid cancer?"), the exact cause of most thyroid cancers is not yet known. Researchers have made great progress in understanding how certain changes in a person's DNA can cause thyroid cells to become cancerous. 

• DNA is the chemical in each of our cells that makes up our genes – the instructions for how our cells function. We usually look like our parents because they are the source of our DNA. However, DNA affects more than how we look. It also can influence our risk for developing certain diseases, including some kinds of cancer.

• Some genes contain instructions for controlling when our cells grow and divide. Certain genes that speed up cell division or cause cells to live longer than they should are called oncogenes. Others that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes. Cancers can be caused by DNA changes that turn on oncogenes or turn off tumor suppressor genes.

• People inherit 2 copies of each gene – one from each parent. People can inherit damaged DNA from one or both parents, which accounts for inherited cancers. Most cancers, though, are not inherited. In these cases, a person's DNA is damaged by exposure to something in the environment, like smoking or radiation. Other DNA changes may just be random events that sometimes happen inside a cell, without having an external cause.

Papillary Thyroid Cancer:  Several DNA mutations have been found in some forms of papillary thyroid cancer. Many of these cancers have changes in specific parts of the RET gene. The altered form of this gene, known as the PTC oncogene, is found in about 10% to 30% of papillary thyroid cancers overall, and in a larger percentage of these cancers found in children and/or linked with radiation exposure. These RET mutations usually are acquired during a person's lifetime rather than being inherited. They are present only in cancer cells and are not passed on to the patient's children.

• Many (30% to 70%) papillary thyroid cancers contain a mutation of the BRAF gene. The BRAF mutation is less common in thyroid cancers in children and in those thought to arise from exposure to radiation. Cancers with BRAF changes tend to have more aggressive growth and a greater likelihood of spreading to other parts of the body. 

• Both BRAF and RET/PTC changes are thought to cause cells to grow and divide. It is extremely rare for papillary cancers to have changes in both the BRAF and RET/PTC genes. Some doctors now advise testing papillary cancer samples for these gene mutations, as some studies have suggested they may affect a person's prognosis (outlook). 

• Changes to other genes have also been tied to papillary thyroid cancer, including those in the NTRK1 gene and the METgene.

Follicular Thyroid Cancer:  Acquired changes in the RAS oncogene have a role in causing some follicular thyroid cancers.

Anaplastic Thyroid Cancer:  These cancers tend to have some of the mutations described above and often have changes in the p53 tumor suppressor gene and the CTNNB1 oncogene as well.

Medullary Thyroid Cancer:  People who have medullary thyroid carcinoma (MTC) have mutations in different parts of the RET gene compared with papillary carcinoma patients. Nearly all patients with the inherited form of MTC and about 1 of every 10 with the sporadic (non-inherited) form of MTC have a mutation in the RET gene.

• Most patients with sporadic MTC have acquired mutations present only in their cancer cells. Those with familial MTC and MEN 2 inherit the RET mutation from a parent. These mutations are present in every cell of the patient's body and can be detected by testing the DNA of blood cells.

• In people with inherited mutations of RET, one RET gene is usually normal and one is mutated. Because every person has 2RET genes but passes only one of them to a child (the child's other RET gene comes from the other parent), the odds that a person with familial MTC will pass a mutated gene on to a child are 1 in 2 (or 50%).

Last Medical Review: 06/29/2011

Last Revised: 01/20/2012

New treatment approach for Anaplastic Thyroid Cancer results in prolonged survival

CHICAGO -- Aggressive treatment of anaplastic thyroid carcinoma has dramatically increased survival in the small group of patients who chose to undergo it, say physicians at Mayo Clinic. Their findings will be presented at the annual meeting of the American Society of Clinical Oncology, to be held June 4-8 in Chicago.

Mayo oncologists say this new approach reflects the need to aggressively treat metastasis even when this rare cancer seems to be confined to the neck. Historically, anaplastic thyroid cancer has been treated with surgery and radiation, but due to rapid spread of microscopic cancer, only between 10 and 20 percent of patients survive past a year. Because the prognosis for this cancer is so poor, Mayo physicians felt that a more aggressive pilot approach that added in chemotherapy early on was merited.

Of 24 patients with newly diagnosed anaplastic thyroid cancer seen at Mayo Clinic between 2003 and 2007, 10 patients with local disease elected to pursue the aggressive approach. After surgery, the patients were treated with intensity modulated radiation therapy (IMRT), a more tailored form of radiation therapy than has been used before, and with aggressive chemotherapy (docetaxel and doxorubicin) in efforts to simultaneously control disease in the neck and forestall metastasis.

One-year survival in this group was 70 percent, with six of the 10 patients (60 percent) alive at least two years post-treatment -- five of them without evidence of disease. Two of these patients were treated more than three years ago and are still in remission.

"The results are far superior to what we have seen before or even expected were possible," says Keith Bible, M.D., Ph.D., a lead investigator of the study, along with Robert Foote, M.D., and Julian Molina, M.D., Ph.D.

However, the benefits come at the cost of toxicity, the researchers add. "Toxicity is a very real issue, to the point that many patients required hospitalization related to side effects from the therapy, but no deaths resulted from therapy," says Dr. Bible, who is presenting the results. Of the four patients who have died to date, all succumbed to their disease, not to treatment effects.

Dr. Bible added that a clinical trial formally testing two approaches to the addition of chemotherapy to radiotherapy in a randomized fashion will be launched in the fall and will include other centers nationwide. The new study will use a related chemotherapy drug, paclitaxel, as well as the addition of a targeted therapy. Dr. Bible will co-lead the study along with Eric Sherman, M.D., from Memorial Sloan-Kettering Cancer Center and others.

Mayo Clinic is regarded as a center of excellence for the treatment of anaplastic thyroid cancer due to the clinic's specialization in thyroid and endocrine cancers -- an expertise that dates back to the practice of thyroid surgeon Charles H. Mayo, M.D., one of the founders of Mayo Clinic. "We have become seriously focused on how to treat these and other rare endocrine cancers more effectively," Dr. Bible says.

SOURCE:  Mayo Clinic