Diagnosis for Thyroid tumor
Differentiated Thyroid cancer
Frequently, for differentiated thyroid cancer, the diagnosis is unmethodical: following radiological exams performed for other problems or check ups.
For patients subjected to neck irradiation in the case of thyroid neoplasms, with the presence of rapidly growing thyroid nodules, hard or fixed, or in the case in which suspected lymph nodes appear in the neck, it is recommended to perform an ultrasound to discriminate which are the nodules on which is necessary to perform a needle aspiration.
Only in the specific case in which the ultrasound suggests an extra capsular extension or a mediastinal involvement, one can perform a CAT (computed axial tomography) of the neck or an MR (magnetic resonance).
Medullary Thyroid cancer
For a medullary thyroid cancer, the case is different:
In 1 case out of 2, neck lymph nodes are involved and can be the first signs of the disease an in 1/5 cases liver, lung and bone metastasis appear in the body.
The dosage of calcitonin serum is a screening test for medullary thyroid cancer, as well as CEA (Carcinoembryonic antigen) that has to be dosed along with calcitonin.
An Ultrasound, followed by a needle biopsy, is the diagnostic exam of reference followed by a second level investigation such as CAT or MRI (nuclear magnetic resonance imaging ).
A PET with radio-marked glucose (FDG) is instead less sensitive and a Gallium 88 is suggested.
Furthermore, in all medullary thyroid cancer patients, it is necessary to carry out a study on the mutation of the RET gene, indicator of a inherited transmission and therefore an increased risk factor to develop a medullary thyroid cancer. In the presence of a mutation in the patient, all family members must receive screening.
Anaplastic Thyroid cancer
Anaplastic thyroid cancer is, among the different thyroid cancers, the most aggressive: for 80% of the cases it presents itself as a locally advanced disease with the participation of neck lymph nodes and similarly to differentiated thyroid cancer, 50% of the patients already have lung , bone or brain metastasis at diagnosis, with the necessity to undergo a PET with FDG to better characterize the metastatic disease. Furthermore, a laryngoscopy test or a panendoscopy test allow to evaluate the respiratory space and the involvement of the neck structures that assist in the processes of respiration and alimentation.
Therapy for Thyroid cancer
The therapeutic approaches for the treatment of a thyroid tumor are:
– Radiometabolic therapy (only for differentiated thyroid cancer)
– Hormonal therapy
– Biological therapy
The decision for differentiated tumors depends on the level of risk:
* Low risk:
– Absent Metastasis
– Absence of residual tumors
– Non invasive and non aggressive tumor
* Intermediate risk:
– Presence of tissue invasion around the thyroid
– Involvement of neck lymph nodes
– Iodine uptake by the tissues surrounding the thyroid after the first radiometabolic treatment
* Elevated risk:
– Invasive tumor
– Tumor that hasn’t been fully removed by surgery
– Presence of Metastasis
– High values for thyroglobulin or in high increase
If the tumor is still small (<4cm) and has been identified (negative lymph nodes), it is resected through surgery resulting in the complete removal (total thyroidectomy) or partial (hemithyroidectomy) removal of the thyroid (low risk). In the case of an extracapsularity risk or of a lymph nodal involvement, the resection will have to total (high risk), associated with the removal of the neck’s lymph nodes (lymphadenectomy). The adjuvant therapy (following surgery) with radioactive iodine (metabolic therapy) is taken into consideration in the case of differentiated thyroid tumors (papillary and follicular) and in the presence of:
– Tumor > 1 cm or an aggressive tumor
– Tumors > 4 cm
– Extrathyroidal extension
– Lymph nodal localizations (pN+): in the histologic aggressive form for tumors
In any case, Hormonal therapy with recombinant TSH with a dose that maintains TSH at a limit inferior to the normal range, is always recommended to reduce the risk of recurrence.
If after the surgical operation and the radiometabolic therapy, there is a relapse of the disease (recurrence) or evidence of persistence, the doctor will evaluate if a new surgery operation is necessary and if that is not the case, plan a treatment with external beam radiotherapy. In the case of a slow growth for the disease, highly localized and small (<3cm) in patients at low risk, on can initially proceed with strict check ups and only intervene in a second moment.
If the disease is in an advanced state that involves other organs (metastatic), the steps to take are radiometabolic therapy, after performing a scintigraphy, to verify the sensitivity to iodine.
In the case of diseases resistant to Iodine and in progression to radiometabolic therapy, biological therapy with TKI inhibitors (ex. Sorafenib and Lenvatinib) is suggested.
In case of progression with biological therapy, patients who show good general conditions can undergo chemotherapy with Adriamycin 60 mg/m2 every 3 weeks with a total of 459mg/m2 maximum to avoid side effects on the heart. Subsequently taxol or taxothere treatment could be evaluated as a possibility although there isn’t still enough data in favor of the benefits of these drugs.
For medullary tumors, due to the scarce results with medical therapy (radiometabolic and radiotherapy), surgery is the only truly effective therapy with the removal of the thyroid (total Thyrodectomia) and eventually lymph nodes of the neck. The hormonal therapy with levothyroxine needs to be started 4-6 weeks after total Thyrodectomia.
Even for these types of tumors, in the case of recurrence, surgery is the main choice but if not applicable, external beam radiotherapy is the alternative choice. It is applicable in the case of risk factors such as: disease that has affected the tissues surrounding the thyroid, disease extended to the mediastinum, post surgery residual disease. Radiotherapy is to be considered for diseases that extensively affect the lymph nodes and in the presence of extracapsularity (the disease extends from the lymph nodes to the surrounding tissues).
The drugs that are currently available are 2 inhibitors: Vandetanib and Cabozantinib. The next choice is chemotherapy with Adriamycin associated or not to cisplatin or dacarbazine associated or not with 5-fluorouracil.
For anaplastic cancer, the first choice of treatment is surgery (total Thyrodectomia) with removal of neck lymph nodes (lymphadenectomy) possibly preceded by external beam radiotherapy or chemotherapy concomitant with radiotherapy when possible to reduce the tumor mass or followed by the same (within 3 weeks of surgery) to increase control on the local and lymph node disease (locoregional).
The treatment of chemotherapy associated with radiotherapy is instead the best choice for the treatment of non removable tumors.
The most frequently used chemotherapeutic drugs for the treatment of a metastatic disease are taxanes (taxol / taxotere), platinants (cisplatin / carboplatin) and Adriamycin, alone or even more effectively in combination.
Risk factors for Thyroid cancer
The main risk factor for the differentiated tumors and also the only one for which a direct correlation is known is the exposure to ionizing radiation for medical, work purposes, etc.
The predisposing factors for the onset of these tumors, however, are:
– Insufficient iodine intake
– Autoimmune thyroiditis
– Multinodular or uninodular goiter
– Thyroid cancer in the family
For medullary tumor the only risk factor is heredity, while for the anaplastic the risk factor is the endemic goiter or the presence of untreated differentiated tumors that subsequently change to aggressive and undifferentiated tumors.
Cases of Thyroid cancer
Differentiated thyroid tumor is the 4th most frequent neoplasia in women and the 5th in men, with an incidence of 11 cases / 100,000 a year for women and 4.7 / 100,000 a year.
Medullary thyroid tumor is a rare tumor, with a frequency of 1 case / 10,000 per year, equivalent between males and females. It is hereditary in 25% of cases, sometimes also associated with true genetic syndromes (MEN).
Even more rare is the anaplastic thyroid tumor, with an incidence in Europe of 0.17 / 100,000 inhabitants. Among patients over 60, the female sex is the most affected.
Doctors Ultra-Specialized in the diagnosis and treatment of Thyroid tumor
Dr. Mirabile Aurora
Oncologist in Milan
Thyroid cancer, Head and neck cancer, Oral cavity cancer, Laryngeal cancer, Pharyngeal cancer, Salivary gland cancer, Nasal cavity and paranasal sinus cancer,
Dr. Zurrida Stefano
Oncologist in Milan
Breast cancer, Melanoma,
Molecular biology, Health education
Dr. Castellino Laura
Endocrinologist in Milan
Thyroid cancer, Endocrine tumors,
Diseases of the thyroid, pituitary gland, adrenal gland, of parathyroids and calcium-phosphorus metabolism, Diabetes and metabolic syndrome, Gynecological endocrinology, Rare endocrine diseases
Dr. Bondi Stefano
Otorhinolaryngologist in Milano
Oncological Surgery for Head-Neck,
Oral Cavity Surgery, Oropharynx Surgery, Laryngeal-Hypopharyngeal Surgery,
Nasal Surgery, Paranasal sinuses Surgery
Dr. Dell’Oca Italo
Radiotherapist in Milan
Brain cancer,Ocular cancer,
Oral cavity cancer, Pharyngeal cancer, Laryngeal cancer, Esophageal cancer,
Lung cancer, Pleural Mesothelioma cancer, Thymus cancer
Dr. Tubere Giorgio
Palliative care in Sanremo
Dr. Finocchiaro Claudia Yvonne
Psycho-oncologist in Milan
Dr. Tubere Giorgio
Psycho-oncologist in Sanremo