Diagnosis Disparities in Minorities Study

Results from one study show that despite a lower overall rate of thyroid cancer, African-Americans are generally diagnosed with a higher grade of cancer than in Caucasian populations.

Other studies have been published indicating economic issues chiefly underlie the differences in cancer stage upon diagnosis.

Lower levels of access to medical care due to economic constraints, or the inability to take time off from work have been linked to a longer time between the first symptoms of cancer and the beginning of cancer treatment.

The figure shows the thyroid cancer incidence rates by race and ethnicity for the US male and female in 2007. The thyroid cancer incidence rates are per 100, 000 US population and are age-adjusted to the 2000 US Standard Population 

Results from the study show that African Americans had double the rate of anaplastic thyroid cancer, an advanced and aggressive stage of thyroid cancer, when compared to Caucasian thyroid cancer patients.  African American patients were also twice as likely as Caucasian patients to have tumors larger than four centimeters.

Ask your doctor about screening tests for Thyroid Cancer.

The study used the National Cancer Institute’s database to look at data for the years 1992-2006, tracking five year survival rates of thyroid cancer patients in 17 states. Study data examined the cases of 26,902 patients diagnosed with thyroid cancer during that time.

“We think that the mortality rate is probably due to an access to care issues,” said Christopher Hollenbeak, PhD and lead study author.

“African-Americans were more likely to present with tumors larger than four centimeters, which implies that the tumors sat there and grew a lot longer,” he said.

Papillary and follicular cancer are the most common forms, and usually diagnosed in susceptible populations such as Caucasian or Asian groups. Complete treatment success for papillary and follicular thyroid cancers is close to 90 percent.

Anaplastic thyroid cancers, on the other hand, which were shown to be more commonly diagnosed in African American patients with thyroid cancer, can be fatal much more frequently.

One surgeon interviewed agreed that the difference could be amount of time elapsed from the cancer developing, to being treated. If caught early thyroid cancer treatment usually involves a small surgery, with some patients needing to take a small amount of radioactive iodine to completely destroy the cancer.

"The prevailing theory today is that anaplastic is thyroid cancer that goes haywire from not being treated,” said David Goldberg, MD, co-author of the study and currently a professor at Penn State.

The study was published in the journal Ethnicity & Disease. Authors denied any financial conflict of interest arising from the publication of their results.

Thyroid Cancer Screening and Prevention

Thyroid cancer can often be found early. Most early thyroid cancers are found when patients ask their doctors about lumps or nodules they have noticed or when doctors find a lump during a routine checkup.

No blood tests are regularly recommended for early detection of sporadic (not familial or inherited) thyroid cancers. However, some doctors recommend that people examine their own neck twice a year to look for growths or lumps.

If you have a family history of medullary thyroid carcinoma (MTC) with or without type 2 multiple endocrine neoplasia (MEN 2), you could be at very high risk of thyroid cancer. If so, most doctors would recommend that you have genetic testing to find out if you carry the gene for MTC. This can be done by a simple blood test. 

Prevention

Most people with thyroid cancer have no known risk factors, so it is not possible to prevent most cases of this disease. Some doctors believe that the increase in thyroid cancers in recent years is due to x-ray testing of young children. This has not been proven, but it is a good idea for children to avoid x-rays that are not necessary.

Because of the genetic blood tests now available, most familial cases of medullary thyroid carcinoma (MTC) can be treated early or prevented. If you have a family history of MTC, you should see a doctor who is familiar with the latest advances in genetic counseling and genetic testing for this disease. The rest of your family (your brothers, sisters, and children) should also be tested to see if they also have mutation in the RET gene that causes MTC.

Almost all children and adults who have positive genetic tests results for the RET gene mutation will develop MTC at some time. To prevent MTC, most doctors recommend surgery as soon as possible, even in children. Removing the thyroid gland in people who carry the abnormal gene will prevent a cancer that might otherwise be fatal.

• Preventive (prophylactic) surgery - If you have inherited a defective RET gene, which can cause MTC in you and other family members, your doctor may recommend that your thyroid gland be removed by surgery (total thyroidectomy) even if it seems to be healthy. This eliminates the risk of MTC. However, it does not reduce the likelihood of adrenal or parathyroid tumors if you have multiple endocrine neoplasia, type II (MEN 2).

According to the Mayo Clinic, a healthy diet might be able to reduce your risk of thyroid cancer:

• A healthy diet - A diet high in fruits and vegetables and low in animal fat can reduce your risk of many types of cancer. The American Cancer Society recommends eating at least five servings of fruits and vegetables every day. They contain antioxidants, which protect your cells from damage. In addition, you should eat plenty of unsaturated fats (omega-3 fatty acids), especially those in salmon and other fish, because they may help protect against cancer. Keeping a healthy weight can also help protect against many diseases, including thyroid cancer.

If a nuclear power plant has an accident or is attacked, the resulting nuclear fallout could increase the risk of thyroid cancer in people living in the area. The U.S. government recommends that people who live within 10 miles of these plants store potassium iodide tablets just in case they need to protect themselves from the effects of nuclear fallout.

• Potassium iodide tablets - Potassium iodide protects your thyroid gland from iodine 131 (a component of nuclear fallout that can cause thyroid cancer) if you take it just before or right after you are exposed to nuclear fallout. However, potassium iodide does not protect you from other radioactive material. Children are most at risk from exposure to radioactive iodine, and potassium iodide is safe and effective for even very young children when they take the proper dosage.

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

Hormone Therapy for Thyroid Cancer

The thyroid gland makes a hormone (thyroid hormone) that helps control your heart rate, body temperature, and energy level. A gland in your brain (pituitary gland) constantly monitors the amount of thyroid hormone in your blood. 

If you do not have enough thyroid hormone, your pituitary releases extra thyroid-stimulating hormone (TSH), which tells your thyroid to absorb iodine from the blood and use it to make more thyroid hormone. Your thyroid gland then makes and releases the hormone directly into your bloodstream. Your pituitary gland senses that the right amount of thyroid hormone is moving through your body, so it slows its production of TSH back to normal.

After you have any kind of thyroid surgery, your body will no longer be able to make the thyroid hormone it needs. You will therefore need to take thyroid hormone replacement pills to give your body the natural thyroid hormone it can no longer make on its own. 

If you have follicular or papillary cancer, the thyroid hormone pills can also slow down the growth of any cancer cells that are left in your body. 

The generic name of the hormone is levothyroxine sodium. It is sold as Synthroid^®, Levoxyl^®, Levothroid^®, Unithroid^®, and other brand names.

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

Surgery for Thyroid Cancer

Surgery is the main treatment for all types of thyroid cancer and is used in nearly every case, except anaplastic thyroid cancer. 

• Lobectomy - Lobectomy is the removal of only the affected side of the thyroid gland. If you have a papillary cancer that is smaller than 1 centimeter (about ½ inch) and there is no sign that it has spread beyond the thyroid gland, the surgeon may perform a lobectomy.

• Thyroidectomy - The surgeon removes most or all of the thyroid gland.

• Near-total (sub-total) - This is the most common type of surgery for thyroid cancer. Because papillary thyroid cancer is often located in both left and right sides of the thyroid gland (multifocal) and because follicular cancer is more aggressive, most surgeons will remove nearly all of the thyroid gland. However, the surgeon leaves small amounts of tissue around the parathyroid glands (which produce a hormone that helps control the levels of calcium and phosphorus in the body) to reduce the risk of damage to these glands.

• Total- 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.

• Neck dissection - If you have a near-total (sub-total) or total thyroidectomy, your surgeon might also perform a neck dissection. The surgeon removes lymph nodes in the front and side of the neck that may contain cancer. Neck dissection is sometimes the best way to prevent medullary thyroid cancer (MTC) from spreading or coming back after treatment (recurring).

• Radical - The surgeon removes all of the lymph nodes on one side of the neck from the lower edge of the jaw to the upper edge of the collarbone. The surgeon also takes out sections of muscle, nerve, and the large veins in the neck.

• Modified radical - The surgeon removes all of the lymph nodes on one side of the neck from the lower edge of the jaw to the upper edge of the collarbone. However, the surgeon does not take out sections of muscle, nerve, and the large veins in the neck.

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

Thyroid Cancer Treatment Basics Update

Your stage of thyroid cancer  and your overall health will determine the method your doctor recommends for treating your illness. The mains ways of attacking thyroid cancer are surgery, radiation, chemotherapy (drugs), and thyroid hormone therapy.

Your doctor will work with you to choose the best treatment for your thyroid cancer based on:

• Your age, overall health, and medical history
• Type of thyroid cancer
• Extent of the disease
• Grade and stage of the cancer
• Your tolerance of specific medicines, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference

All treatments have benefits and risks. You and your doctor should carefully balance the potential benefits of any cancer treatment with its potential risks. After the thyroid cancer is diagnosed and staged, your physician will recommend a treatment plan. 

Your treatment may include:

• Surgery - Surgery is the main treatment for all types of thyroid cancer and is used in almost every case, except anaplastic thyroid cancer. Doctors usually recommend surgery for thyroid cancer to remove the tumor and all or part of the remaining thyroid gland.

• Radioactive Iodine -  Your thyroid gland absorbs nearly all of the iodine in your blood. When a large enough dose of radioactive iodine (RAI), also known as I-131, is taken into the body, it can destroy the thyroid gland and any other thyroid cells (including cancer cells) that take up iodine, with little effect on the rest of your body. The radioactive iodine is usually given as a capsule or liquid. This treatment can be used to destroy (ablate) any thyroid tissue not removed by surgery or to treat thyroid cancer that has spread to lymph nodes and other parts of the body.

• Radiation therapy - Radiation therapy uses high-energy radiation to kill cancer cells and shrink tumors.

• Chemotherapy - Chemotherapy drugs are used to kill cancerous cells. In most cases, chemotherapy works by stopping cancer cells from growing or reproducing, which kills the cells. Different types of chemotherapy drugs work in different ways to kill cancer cells. Chemotherapy, often in combination with radiation therapy, is often used to treat anaplastic thyroid cancer, which is typically found too late for surgery. It is sometimes used to treat medullary thyroid cancer (MTC). But it is rarely helpful for other types of thyroid cancer.

• Thyroid hormone therapy - After you have thyroid surgery, your body will no longer be able to make the thyroid hormone it needs. You will therefore need to take thyroid hormone replacement pills to give your body the natural hormone that it cannot produce without a thyroid. Also, the thyroid pills slow down the growth of any papillary or follicular thyroid cancer cells that are still in your body, reducing the chance that these kinds of cancer will come back.

Medullary Thyroid Cancer Follow Up

Dr. Kurt Frederick, talking with patient Leigh Rhodes

Blood calcitonin monitoring is the most sensitive test to identify persistent recurrent tumor in patients with MTC.  Patients can have loco-regional or distant metastasis as their primary site of recurrence. Ultrasound of the neck by an experienced ultrasonographer is the most sensitive method for identifying residual disease.

• If the plasma calcitonin is not elevated, patients should continue to undergo basal and provocative testing annually for 5 years. 

• Calcitonin levels in the normal range after total thyroidectomy suggest persistent disease. Calcitonin levels greater than 1000 pg/ mL indicate distant metastasis. 

• Chemotherapy plays a limited role in advanced surgically unamenable MTC in clinical trials.

•  Radioiodine may play a role for destroying and residual normal thyroid tissue, and for patients with mixed tumors of follicular and parafollicular cell origin. Its role, however, is still controversial. 

SOURCE: Weill Cornell Medical College

Pediatric Thyroid Cancer Update

Where  is the Thyroid Gland? What does it do?

The thyroid is a butterfly-shaped gland located at the base of the throat. It has two lobes joined in the middle by a strip of tissue (the isthmus). The thyroid secretes three main hormones: 

1) Thyroxine, that contains iodine, needed for growth and metabolism; 

2) Triiodothyronine, also contains iodine and similar in function to Thyroxine; and 

3) Calcitonin, which decreases the concentration of calcium in the blood and increases calcium in the bones. All three of these hormones have an important role in your child’s growth.

Fast Facts:

• Thyroid cancer is the third most common solid tumor malignancy and the most common endocrine malignancy in children. 

• Thyroid Cancer occurs four times more often in young girls than boys and has similar characteristics as adult thyroid cancer. 

• Surgery is the preferred treatment for this cancer. Although the procedure is often uncomplicated, risks of thyroid surgery include vocal cord paralysis and hypocalcemia (low blood calcium). 

• Consequently, an otolaryngologist—head and neck surgeon, one experienced with head and neck issues, and specifically pediatric thyroid cancers should perform surgery.

Types of Thyroid Cancer in Children

• Papillary: This form of thyroid cancer occurs in cells that produce thyroid hormones containing iodine. This type, the most common form of thyroid cancer in children, grows very slowly but it  can spread to the lymph nodes via lymphatics in the neck and occasionally spreads to more distant sites if not diagnosed and treated early or properly.

• Follicular: This type of thyroid cancer also develops in cells that produce thyroid hormones containing iodine. The disease afflicts a slightly older age group and is less common in children. This type of thyroid cancer is more likely to spread to the neck via blood vessels, causing the cancer to spread to other parts of the body, making the disease more difficult to control in growing children.

Papillary and Follicular Thyroid Cancers are classified as well differentiated thyroid cancers.

• Medullary: This rare form of thyroid cancer develops in cells that produce calcitonin, a hormone that does not contain iodine. This cancer tends to spread to other parts of the body and constitutes about 5-10 percent of all thyroid malignancies in children worldwide. Medullary thyroid carcinoma (MTC) in the pediatric population is usually associated with a specific inherited genetic conditions, such as multiple endocrine neoplasia type 2 (MEN2). Sporadic Medullary thyroid cancers are less common in children.

• Anaplastic: This is the fastest growing and most aggressive type thyroid cancers, with abnormal cells that grow and spread rapidly, especially locally in the neck. There is NO cure for anaplastic thyroid cancer and survival rates are generally less than a year from diagnosis date. This form of cancer has not been documented in children.

Symptoms: Symptoms of this disease vary. Your child may have a lump or nodule in the neck (similar to a goiter), persistent swollen lymph nodes, a tight or full feeling in the neck, trouble with breathing or swallowing, dry cough not associated with allergies or cold,  voice changes and hoarseness. Sometimes hormonal problems associated with thyroid disease are evident, such as mood swings, palpitations or weight gain. 

Diagnosis: If any of these symptoms occur, or you have a family history of thyroid disease, thyroid nodules, tumors, goiter or thyroid cancer ask your pediatrician to check your child's neck as part of his or her regular annual physical or health examinations. The evaluation should consist of a manual head and neck examination to determine if unusual lumps are present. 

A blood test may be ordered to determine how the thyroid is functioning. If a nodule or tumor is found or if your child develops a "goiter " (which is rare) an ultrasound or ultrasonography uses sound waves and a computer to create an image of the thyroid gland and neck contents such as lymph nodes to better evaluate the presence of abnormal growths. 

Other tests that may be warranted include a radioactive iodine scan, which provides information about the thyroid shape and function, identifying areas in the thyroid that do not absorb iodine in the normal way, or a fine needle biopsy of any abnormal lump in the thyroid or neck.  Sometimes it is necessary to remove a part of the tumor or one of the lobes of the thyroid gland, known as a thyroid lobectomy, for analysis to help establish a diagnosis and plan for management.

Treatments for thyroid cancer: If the tumor is found to be malignant, then surgery is recommended. Surgery may consist of a lobectomy, subtotal thyroidectomy (removal of at least one lobe and up to near-total removal of the thyroid gland), or a total thyroidectomy. In children with papillary or follicular thyroid cancer, total or near-total thyroidectomy is currently the standard of practice, as children typically have more extensive disease at presentation, have higher rates of spread, and it reduces the risk of  recurrence. 

• Please note that in children, there is an increased need for repeat surgery when less than a total thyroidectomy is performed. Lymph nodes in the neck may need to be removed as part of the treatment for thyroid cancer if there is suspicion of spread of cancer to the lymph nodes.

• Surgery may be followed by radioactive iodine therapy, to destroy cancer cells that are left after surgery. Thyroid hormone therapy may need to be administered throughout your child’s life to replace normal hormones and slow the growth of any residual cancer cells.

• If cancer has spread to other parts of the body, such as the bones, lungs or other endocrine organs chemotherapy (treatment by chemical substances or drugs) may be given. This therapy interferes with the cancer cell’s ability to grow or reproduce. Different groups of drugs work in different ways to fight cancer cells and shrink tumors. Radiation treatment may also be required for treatment of some forms of thyroid cancer.

• In general, treatment outcomes and prognosis for well differentiated thyroid cancers in children diagnosed and treated early tend to be excellent. The best outcomes are seen in teenage girls, papillary type thyroid cancer, and tumors localized to the thyroid gland.

PDF DOWNLOAD:  Diagnostic and Treatment Options for papillary, follicular and Hurthle Cell  thyroid carcinoma review by Cristian M. Slough MD and Gregory Randloph MD 

SOURCE:   American Academy of Otolaryngology, Head and Neck Surgery

Well Differentiated Thyroid Cancer Follow Up

Papillary and/or Follicular thyroid cancer will recur or persist in about 25% of patients, and 80% of these recurrences will be in the neck. Recurrence occurs most commonly in the first 2 years after thyroidectomy. In papillary thyroid cancer, however, recurrence can occur up to 45 years after surgery, whereas virtually all patients with follicular and Hürthle cell cancer recur before 12 years after surgery.

• The current recommendations for postoperative follow-up of well-differentiated thyroid cancer, except for very low-risk patients, are thyroid remnant ablation and thyroid stimulating hormone (TSH) suppression. 

• Radioiodine ablation is recommended for patients with papillary thyroid cancers larger than 1.5cm, multifocal tumors, and for those with lymph node metastases. 

• Invasive follicular and Hürthle cell cancer also warrant radioiodine therapy.  

• Doctors routinely recommend the  use 30 to 50 mCi of radioiodine in low risk and 100 to 200 mCi of radioiodine in high-risk patients. 

• The initial radioiodine treatment should be performed under hormone withdrawal, or with recombinant TSH stimulation 6-8 weeks post operatively in an iodine deficient patient. 

• Patients should have a thyroid hormone levels (TSH, T3, T4, Thyroglobulin) measured as well  pregnancy test prior to 131-Iodine scanning and ablation therapy, and post-treatment imaging. 

TSH  is known to stimulate tumor growth, invasion, angiogenesis, and thyroglobulin secretion. Therefore post operatively patients are placed on thyroid hormone replacement therapy. 

• In  low-risk patients doctors maintain the serum TSH level just below the lower limit of the normal range between 0.1 and 0.4 mU/ mL. 

• In high-risk patients the dosage is adjusted to maintain a serum TSH level less than 0.1 mU/ mL, as this has been reported to improve tumor free survival. 

Adverse effects of TSH suppression may include:  

• subclinical thyrotoxicosis 
• exacerbation of angina 
• atrial fibrillation
• osteoporosis in postmenopausal women

External beam radiation and chemotherapy have a limited role in the postoperative management of well differentiated thyroid carcinoma patients. 

• External beam radiation is used infrequently in the management of thyroid cancer except as a palliative treatment for locally advanced unresectable disease, positive tumor margins, or recurrent disease after re-resection. 

• Chemotherapy has shown only minimal benefit in the treatment of well-differentiated thyroid cancer. New clinical trials have recently become available.

Follow-up is different for patients at low, intermediate, and high risk of having persistent or recurrent disease. 

• Low risk patients are defined as patients with no local or distant metastases, complete resection of tumor contained within the thyroid with no locoregional invasion, tumor without aggressive histology, and if radioiodine was given there was no uptake outside of the thyroid bed. 

• Intermediate risk patients have microscopic invasion of tumor into the peri-thyroidal soft tissue at initial surgery or tumor with aggressive histology or vascular invasion. 

• High-risk patients have macroscopic tumor invasion, incomplete tumor resection, distant metastases, or radioiodine uptake outside the thyroid bed on the post-treatment scan after thyroid remnant ablation.

The absence of persistent disease in patients that have undergone at least a total thyroidectomy and thyroid remnant ablation comprises of no clinical evidence of tumor, no imaging evidence of tumor, and undetectable serum thyroglobulin levels during TSH suppression and stimulation in the absence of interfering antibodies.

All patients with a history of well-differentiated thyroid cancer should have yearly cervical ultrasound scanning, thyroglobulin and thyroglobulin antibodies. 

• Approximately 20% of patients who are clinically disease free with serum thyroglobulin levels less than 2 ng/mL during thyroid hormone suppression will have a thyroglobulin level greater than 5 ng/mL after rhTSH or thyroid hormone withdrawal. One third of this group will have persistent disease identified on imaging studies. Therefore, a serum thyroglobulin level above 5 ng/mL after rhTSH stimulation is highly sensitive in identifying patients with persistent disease. Furthermore, the clinical significance of minimally detectable thyroglobulin levels is unclear, especially if only detected after TSH stimulation. 

• Approximately 25% of patients with thyroid cancer have antithyroglobulin antibodies making follow-up with thyroglobulin insensitive. In this group serial serum antithyroglobulin antibody measurements may serve as an imprecise surrogate marker to detect recurrence among these patients. Accurate surveillance for possible recurrence and treatment in patients thought to be free of disease is a major goal of long-term follow-up.

SOURCE: Weill Cornell Medical College

Understanding Thyroid Gland Surgery Options

There are several surgical pptions for the thyroid gland nodules, tumors and diseases. Which operation is performed on a thyroid gland depends upon two major factors:

1.    Thyroid disease present requiring surgery.

2.    Anatomy of the thyroid gland itself, tumor or nodule involved.

If a dominant solitary nodule is present in a single lobe, then removal of that lobe is the preferred operation (if an operation warranted).  

If a massive goiter is compressing the trachea and esophagus, the goal of surgery will be to remove the mass, and usually this means a sub-total or  total thyroidectomy (occasionally a lobectomy will suffice).

If a hot nodule is producing too much hormone resulting in hyperthyroidism, then removal of the lobe that harbors the hot nodule is all that is needed.

Most surgeons and endocrinologists recommend total or near total thyroidectomy in virtually all cases of thyroid carcinoma. In some patients with small papillary carcinomas, a less aggressive approach may be taken (lobectomy with removal of the isthmus).

A lymph node dissection within the anterior and lateral neck is indicated in patients with well differentiated (papillary or follicular) thyroid cancer if the lymph nodes can be palpated. This is a more extensive operation than is needed in the majority of thyroid cancer patients.

All patients with medullary carcinoma of the thyroid require total thyroidectomy and aggressive lymph node dissection.

Partial Thyroid Lobectomy: This operation is not performed very often because there are not many conditions which will allow this limited approach. Additionally, a benign lesion must be ideally located in the upper or lower portion of one lobe for this operation to be possible.

Thyroid Lobectomy: This is typically the "smallest" operation performed on the thyroid gland. It is performed for solitary dominant nodules, which may be thyroid cancer or those which are indeterminate following fine needle biopsy. This surgery may also be appropriate for follicular adenomas, solitary hot or cold nodules, or goiters which are isolated to one lobe (not common).

Thyroid Lobectomy with Isthmusectomy: This simply means removal of a thyroid lobe and the isthmus (the part that connects the 2 lobes). This removes more thyroid tissue than a simple lobectomy, and is used when a larger margin of tissue is needed to assure that the "problem" has been removed. Appropriate for those indications listed under thyroid lobectomy as well as for Hurthle cell tumors, and some very small and non-aggressive thyroid cancers.

Subtotal Thyroidectomy: Just as the name implies, this operation removes all the "problem" side of the gland as well as the isthmus and the majority of the opposite lobe. This operation is typical for small, non-aggressive thyroid cancers. Also a common operation for goiters that are causing problems in the neck or even those which extend into the chest (substernal goiters).

Total Thyroidectomy: This operation is designed to remove all of the thyroid gland. It is the operation of choice for all thyroid cancers which are not small and non-aggressive in young patients. Many surgeons prefer complete removal of thyroid tissue for all types of thyroid cancer.

Surgical Technique: The standard neck incision is made typically measuring about 4 to 5 inches in length, although many endocrine surgeons are now performing this operation through an incision as small as 3 inches in thin patients. This incision is made in the lower part of the central neck and usually heals very well. It is almost unheard of to have an infection or other problem with this wound. The surgeon will then typically remove part or all of the thyroid.

As mentioned above, for thyroid cancer, this will usually entail all of the thyroid lobe that harbors the malignancy, the isthmus, and a variable amount of the opposite lobe (ranging from 0% to 100%, depending on the size and aggressive nature of the cancer, the cancer type, and the experience of the surgeon).

The surgeon must be careful of the recurrent laryngeal nerves, which are very close to the back side of the thyroid and are responsible for movement of the vocal cords. Damage to this nerve will cause hoarseness of the voice, which is usually temporary but can be permanent. This is an uncommon complication (about 1% to 2% of patients experience this), but it is serious.

Your surgeon must also be careful to identify the parathyroid glands so their blood supply can be maintained. Another potential complication of thyroid surgery—although  rare—is hypoparathyroidism which is due to damage to all 4 parathyroid glands.  Usually the only thyroid operations that have even a slight chance of this complication is the total or subtotal thyroidectomy. 

Although the complications mentioned can be serious, their risk should not be the sole determinant of whether or not to undergo surgery. Often, formal thyroid surgery is not needed to determine if a thyroid mass is cancerous. Because these masses are often palpable, a pathologist  can usually stick a small needle into it to sample cells for malignancy. This is called fine needle aspiration (FNA) biopsy.

The relationship of the thyroid gland to the voice box and parathyroid glands in the image above can be seen quite clearly.  Remember that they share the same blood supply, so the surgeon must take care to preserve the parathyroid artery and vein while ligating the vessels to the thyroid gland itself. This is usually not a problem, but sometimes it is not possible to save them all. In this case, the surgeon will usually implant the parathyroid gland into a muscle in the neck. The parathyroid will re-grow and attach itself there and function normally.

Don't be afraid to ask questions if you don't understand something about your thyroid surgery and what your doctors expectations are for your case. Your surgeon should be able to talk you clearly about all your thyroid surgery options, including total thyroidectomy.

Thyroid Cancer Facts and Stats 2012

As you know January is Thyroid Health Awareness Month and Stevie JoEllie's Cancer Care Fund is officially launching the 10,000 Strong Against Thyroid Cancer Campaign. Here is a list of the most common unknown facts about thyroid cancer you should learn  and talk to your family doctor about during your next visit.

Did you know? Thyroid cancer is the most common endocrine cancer. Thyroid cancer is a cancerous tumor or growth located within the thyroid gland.


Did you know? Thyroid cancer is one of the few cancers that has increased in incidence rates over recent years. It occurs in all age groups from children through seniors.

Did you know? The American Cancer Society estimates that there where about 48,020 new cases of thyroid cancer in the U.S. in 2011. Of these new cases, about 36,550 will occur in women and about 11,470 will occur in men. About 1,740 people (980 women and 760 men) will die of thyroid cancer in 2011.

Did you know? Many patients, especially in the early stages of thyroid cancer, do not experience symptoms. However, as the cancer develops, symptoms can include a lump or nodule in the front of the neck, hoarseness or difficulty speaking, swollen lymph nodes, difficulty swallowing or breathing, and pain in the throat or neck.

Did you know? There are several types of thyroid cancer: papillary, follicular, medullary, anaplastic, and variants.

• Papillary and follicular thyroid carcinomas are referred to as well-differentiated thyroid cancer and account for 80–90% of all thyroid cancers. Variants include tall cell, insular, columnar, and Hurthle cell. Their treatment and management are similar. If detected early, most papillary and follicular thyroid cancer can be treated successfully.

• Medullary thyroid carcinoma (MTC) accounts for 5-10% of all thyroid cancers. Medullary cancer is easier to treat and control if found before it spreads to other parts of the body. There are two types of medullary thyroid cancer: sporadic and familial. Genetic testing (of the RET proto-oncogene should be performed in all patients with MTC to determine whether there are genetic changes that predict the development of MTC. In individuals with these genetic changes, removal of the thyroid during childhood has a high probability of being curative.

• Anaplastic thyroid carcinoma is the least common and accounts for only 1–2% of all thyroid cancer. This type is difficult to control and treat because it is a very aggressive type of thyroid cancer.

Treatments for thyroid cancer include surgery, radioactive iodine treatment, external beam radiation therapy, and chemotherapy.  In most cases, patients undergo surgery to remove most of the thyroid gland, and are treated with thyroid hormone replacement therapy. For those with papillary and follicular thyroid cancer, the dose of thyroid hormone replacement is usually high enough to suppress thyroid stimulating hormone (TSH) well below the range that is normal for someone not diagnosed with thyroid cancer, to help prevent the growth of cancer cells while providing essential thyroid hormone to the body.


Factors associated with thyroid cancer include a family history of thyroid cancer, gender (women have a higher incidence of thyroid cancer), age (the majority of cases occur in people over 40, although thyroid cancer affects all age groups from children through seniors), and prior exposure of the thyroid gland to radiation. Like women childhood cancer survivors have an increased risk of developing the condition.


While the prognosis for most thyroid cancer patients is very good, the rate of recurrence can be up to 30%, and recurrences can occur even decades after the initial diagnosis. Therefore, it is important that patients get regular follow-up examinations to detect whether the cancer has re-emerged. Monitoring should continue throughout the patient’s lifetime.


Periodic follow-up examinations can include a review of the medical history together with selected blood tests appropriate for the type of cancer and stage of treatment (TSH, thyroglobulin, CEA, and calcitonin levels), physical examination, and imaging techniques (ultrasound, radioiodine whole body scan, chest X-ray, CT, MRI, PET, and other tests).

Stevie JoEllie's Cancer Care Fund  is a thyroid cancer awareness, access to care and free supportive services  project of United Charitable Programs Inc., a registered 501(c) 3 public charity. All donations are tax deductible as allowed by state and federal law. SJCCF  differs greatly from other thyroid cancer organizations  and awareness groups in that it's mission and objective is to alleviate the financial burden placed on patients and survivors of thyroid cancer, not research funding. To learn more about our volunteer opportunities please email info@sjccfthynet.org  subject line: volunteer opportunities

LAST UPDATED: January 2012

Thyroid Surgery Overview: Move Over Frankenstein!

Thyroid surgery is performed in a number of circumstances, including when cancers are found, when enlargement causes cosmetic or respiratory problems, when other forms of treatment are ineffective, and when a pregnant woman's hyperthyroidism cannot be controlled by other means.

In most cases, surgery of the thyroid is not highly complicated, and usually takes no more than two hours. It is frequently performed on an outpatient or overnight basis, with general anesthesia.

There are few complications that result, but when they do, they typically fall into one of two categories: damage to the voice box and / or vocal cords, or damage to the parathyroid glands. If there is damage to the parathyroid glands, this will affect the levels of calcium in the blood, however, this is very rare.

 There are three main types of thyroid surgery:

1.  Total Thyroidectomy -- complete removal of the thyroid.
2.  Subtotal Thyroidectomy -- removal of half of the gland
3.  Thyroid Lobectomy -- removal of only about a quarter of the gland 

Thyroid Gland Removal


Definition: Thyroid gland removal is surgery to remove all or part of the thyroid gland. 

• Total thyroidectomy removes the entire gland.
• Subtotal or partial thyroidectomy removes part of the thyroid gland. 

The thyroid gland is part of the endocrine system and plays a major role in regulating the body's metabolism.

Alternative Names:

• Total thyroidectomy
• Partial thyroidectomy
• Thyroidectomy

 Description: Thyroidectomy is done while you are under general anesthesia (unconscious and pain-free). Sometimes it is done with regional anesthesia (awake, but pain-free). The surgeon makes a cut in the neck and locates the gland. All or part of the thyroid gland, depending on the particular procedure, is removed.

Why is the Procedure  Performed?

• Hyperthyroidism (overactive thyroid)
• Thyrotoxicosis
• Hypothyroidism (underactive thyroid) with enlargement of the gland
• Thyroid Cancer
• Thyroid swelling (nontoxic goiter)
• Hashimoto's disease (a type of hypothyroidism)

 The procedure may also be done if a patient with hyperthyroidism does not want to have radioactive iodine treatment and cannot be treated with anti-thyroid medications.

Surgical Risks 

Risks for any anesthesia include the following:

• Reactions to medications
• Problems breathing

Risks for any surgery include the following:

• Bleeding
• Infection

Additional risks for thyroidectomy include the following:

•  Bleeding and possible airway obstruction
• Temporary or permanent loss of ability to speak due to paralysis of the vocal chords
• Inadequate thyroid function (hypothyroidism)
• Injury to the adjacent parathyroid glands
• Inadequate level of calcium in the blood known as hypocalcemia.

 Outlook (Prognosis)

When performed by experienced endocrine surgeons, the outcome of thyroid surgery is usually excellent. Thyroid function tests may need to continue following thyroid surgery, and thyroid hormone replacement maybe necessary.

Recovery

In general, patients recover rapidly from uncomplicated thyroid surgery. Most patients are able to resume most normal activities within 1-2 weeks.

Reviewed By: J.A. Lee, M.D., Assistant Professor of Surgery, Columbia University Medical Center, New York, NY. Review provided by VeriMed Healthcare Network.

  

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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

Cancer According to the Dictionary

When we hear the words, "You have cancer" the world suddenly stops and we can barely hear anything else. Then when it's time to digest the diagnosis we may still not really know what is cancer. Here we discuss a very basic and general definition of cancer.


Definition of Cancer: 

NOUN: Any of various malignant neoplasms characterized by the proliferation of, anaplastic cells that tend to invade, surrounding tissue and metastasize to new body sites. 1. The pathological condition characterized, by such growths. 2. A pernicious, spreading evil: A cancer of bigotry spread through the community. Characteristics of Cancer 

Abnormality:  Cells are the structural units of all living things. Each of us has trillions of cells, as does a growing tree. Cells make it possible for us to carry out all kinds of functions of life: the beating of the heart, breathing, digesting food, thinking, walking, and so on. However, all of these functions can only be carried out by normal healthy cells. Some cells stop functioning or behaving as they should, serving no useful purpose in the body at all, and become cancerous cells. 

Invasiveness:  Sometimes tumors do not stay harmlessly in one place. They destroy the part of the body in which they originate and then spread to other parts where they start new growth and cause more destruction. ;This characteristic distinguishes cancer from benign growths, which remain in the part of the body in which they start. Although benign tumors may grow quite large and press on neighboring structures, they do not spread to other parts of the body. Frequently, they are completely enclosed in a protective capsule of tissue and they typically do not pose danger to human life like malignant tumors (cancer) do. 

A group of diseases: Although cancer is often referred to as a single condition, it actually consists of more than 100 different diseases. These diseases are characterized by uncontrolled growth and spread of abnormal cells. Cancer can arise in many sites and behave differently depending on its organ of origin. Breast cancer, for example, has different characteristics than lung cancer. It is important to understand that cancer originating in one body organ takes its characteristics with it even if it

spreads to another part of the body. 

For example, metastatic breast cancer in the lungs continues to behave like breast cancer when viewed under a microscope, and it continues to look like a cancer that originated in the breast. 

Uncontrollability: The most fundamental characteristic of cells is their ability to reproduce themselves. They do this simply by dividing. One cell becomes two, the two become four, and so on. The division of normal and healthy cells occurs in a regulated and systematic fashion. In most parts of the body, the cells continually divide and form new cells to supply the material for growth or to replace worn-out or injured cells. For example, when you cut your finger, certain cells divide rapidly until the tissue is healed and the skin is repaired. They will then go back to their normal rate of division. In contrast, cancer cells divide in a haphazard manner. The result is that they typically pile up into a non-structured mass or tumor.