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Thyroid Carcinoma

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Thyroid Carcinoma, Thyroid Cancer, Thyroid Neoplasm

  • See Also
  1. Thyroid Nodule
  • Epidemiology
  1. Incidence of Thyroid Carcinoma: 44,000/year (as of 2024, U.S.)
    1. Three fold increased Incidence in 40 years is a result of greater detection
  2. Gender: 70% of cases are in women
  3. Age: Mean onset at 51 years old
  4. Less common in black patients
  5. Incidence by Nodule type
    1. Single Nodules: 5-10% are carcinoma
    2. Multinodular Goiter: <5% are carcinoma
  • Types
  • Thyroid Carcinoma
  1. Papillary carcinoma (80 to 84%)
    1. Insidious growth
    2. May go undiagnosed until metastases
  2. Follicular Carcinoma (4 to 25%)
    1. Female > Male
    2. Peaks at age 50-60 years
  3. Medullary Carcinoma (5-10%)
    1. Secretes multiple substances including Calcitonin
    2. Associated with Multiple Endocrine Neoplasia
      1. MEN 2a (Sipple's Syndrome)
        1. Pheochromocytoma and Parathyroid hyperplasia
      2. MEN 2b
        1. Pheochromocytoma and mucosal neuroma
  4. Undifferentiated Carcinoma (5-10%)
  5. Thyroid Lymphoma (5%)
  • Risk Factors (and Red Flags)
  1. Male gender (especially under age 40 years)
  2. Age extremes (under age 20 and over age 65)
  3. Rapid painless growth of Thyroid Nodule
  4. Local symptoms consistent with invasion
    1. Dysphagia
    2. Neck Pain
    3. Hoarseness or raspy voice
  5. Head and neck radiation history
  6. Family History of Thyroid malignancy
    1. Thyroid Cancer
    2. Thyroid polyposis (Gardner's Syndrome)
  7. Thyroid fixation to skin or trachea
  8. Hard Nodule on palpation
  • Evaluation
  1. See Thyroid Nodule
  2. Most Thyroid Cancers are asymptomatic (found incidentally on imaging, or palpated on exam)
  • Management
  • Thyroid Cancer
  1. Unilateral microcarcinomas (=1 cm or up to 1.5 cm)
    1. Consider observation without surgical resection
  2. Tumors >1 cm with or without Lymph Node metastases
    1. Surgery with or without Radioactive Iodine
    2. Treatment is curative in most cases of well-differentiated Thyroid Cancer
  3. Recurrent local or regional disease
    1. Surgical resection
  4. Metastatic Thyroid Cancer
    1. Surgical resection or stereotactic body irradiation
  5. Advanced Thyroid Cancer AND genetic mutations (BRAF, RET, NTRK, MEK)
    1. Dabrafenib
    2. Selpercatinib
  6. Thyroid Cancer not responding to Radioactive Iodine
    1. Antiangiogenic multikinase inhibitors (eg, Sorafenib, Lenvatinib, Cabozantinib)
    2. Radioactive Iodine response varies by genetic mutation
      1. RAS Mutations respond to Radioactive Iodine
      2. BRAF V600E mutations tend not to respond to Radioactive Iodine
  1. See Cancer Survivor
  2. Follicular, Hurtle Cell or Papillary Cancer
    1. Visits (history, exam, labs) at 6 and 12 months, then yearly
    2. Labs at 6 and 12 months, then yearly
      1. Thyroid Stimulating Hormone (TSH)
      2. Thyroglobulin Antibody
      3. Thyroglobulin
        1. Ultrasensiitive Thyroglobulin if treated with Radioactive Iodine
    3. Imaging
      1. Neck Ultrasound every 6 months for 1 to 2 years, then yearly
      2. TSH stimulated whole body Radioiodine imaging if high risk for metastatic disease
  3. Medullary Cancer
    1. Serum Calcitonin every 6 to 12 months
    2. Carcinoembryonic Antigen (CEA Antigen) every 6 to 12 months
    3. Additional testing for Multiple Endocrine Neoplasia 2A or 2B
      1. Urine or plasma metanephrine yearly
      2. Plasma Parathyroid Hormone test yearly
  4. References
    1. Carek (2024) Am Fam Physician 110(1): 37-44 [PubMed]
  • Prognosis
  1. Overall 5 year survival: 98%
  2. Papillary carcinoma has the best prognosis of Thyroid Cancer
  3. Medullary Carcinoma and Follicular Carcinoma have a more variable prognosis
  4. Undifferentiated Thyroid Cancer and anaplastic Thyroid Cancer have a worse prognosis
  • References
  1. Boucai (2024) JAMA 331(5):425-35 +PMID: 38319329 [PubMed]