Diseases

Once a lump in the thyroid is discovered, it is important to know whether it is benign or malignant (cancerous).Often an ultrasound is performed to assess whether there is a single nodule or whether multiple nodules are present. Ultrasound can determine whether the nodule is fluid filled or solid. Ultrasound also can determine the general appearance of thyroid looking for inflammation or irregularities and the presence of enlarged lymph nodes nearby that may represent metastatic cancer.Fine needle aspiration biopsy is the procedure performed to obtain a sample of cells from the nodule to determine if it is cancerous. Using ultrasound, a thin needle is placed into the nodule and cells from the nodule are obtained. These cells can be examined under a microscope by a pathologist to determine whether a cancer is present and if so, what type of cancer it is.Results of the aspiration are usually reported as the following:

• Malignant: risk of malignancy is 100%
• Suspicious for malignancy: risk of malignancy is 50% to 75%
• Follicular carcinoma: risk of malignancy is 20% to 30%
• Atypical cells of unknown significance: risk of malignancy is 5%-10%
• Benign: risk of malignancy is less than 1%

Sometimes, the results of the aspiration are unclear and indeterminate, and the aspiration may need to be repeated to get a better sample and more cells to study.Another test involves ingesting radioactive iodine, which is taken up by the thyroid gland. The gland is scanned by a Geiger counter-type of apparatus that determines how much radioactive iodine has been taken up by the gland and any thyroid nodules. If the nodule picks up much of the iodine, it is referred to as a "hot nodule." Such nodules are rarely cancerous. Nodules that take up little to no iodine are referred to as "cold nodules." Although the overwhelming majority of such nodules are benign, 5% turn out to be malignant. Although thyroid scans may be helpful, aspiration of the gland is a much more useful test.Blood tests may be ordered to determine thyroid hormone levels and levels of other hormones and electrolytes, like calcium, within the body. These tests indicate whether the cells of the thyroid produce too much or too little hormone, not if cancer is present.On occasion CT, MRI, or PET scans may be useful in evaluating the neck structures if there is concern that thyroid cancer has spread (metastasis).

Thyroid cancer, like most others, is staged based upon three criteria:

• T = how large the main tumor is when it is found
• N = the presence of cancer in lymph nodes and their location
• M = whether the cancer has spread or metastasized to other parts of the body. Thyroid cancer has been known to spread locally or to distant parts of the body including lungs and bone.

Staging from I to IV, including subgroups, is different for each type of cancer and helps predict outcome and survival. There are also different staging considerations for patients older or younger than age 45 for papillary and follicular thyroid cancers.

There is little one can do to prevent thyroid cancer aside from avoiding excessive exposure to radiation.

Thyroid cancers are classified based upon which cell type is involved.Well differentiated cancers (in which thyroid cells are less abnormal looking) include:

• Papillary thyroid cancer: This is the most common type of thyroid cancer. Papillary thyroid cancer accounts for 80% of cases.
• Hürthle cell carcinoma: This is a rare variant of papillary cancer (also known as oncocytic carcinoma).
• Follicular thyroid cancer: Follicular carcinoma is the second most common type of thyroid cancer. The follicular variety accounts for 10% of cases.
• Medullary thyroid cancer: This thyroid cancer type arises from the C cells in the thyroid. Medullary thyroid cancers (MTCs) comprise 5% of all cases.
• Anaplastic thyroid cancer: This rare cancer involves thyroid cells are very abnormal looking, accounting for 1% of all cases.
• Lymphoma: This rare cancer is most often non-Hodgkin's B cell type.
• Sarcoma: This type of thyroid cancer is very rare.

Children who have had radiation exposure to the neck are at higher risk for thyroid cancer. Studies have looked at children who were radiated 50 and 60 years ago when the risks of radiation where less well understood, and their rate of thyroid cancer is increased. Children and women survivors of nuclear reactor accidents (Chernobyl in 1986 has been studied) have an increased risk of thyroid and other types of cancer.X-rays and CT scans of the neck use low doses of radiation but medical testing has not been found to cause thyroid cancer. Nevertheless, in general, it is important to limit the amount of exposures to the least amount of radiation that will provide a clear enough image to help make a diagnosis.Diets low in iodine may increase the risk of thyroid cancer, but in developed countries, there is usually enough iodine used as food additives that this is not a problem. Lower levels of iodine in the diet may enhance the risk of radiation induced thyroid cancer.Women are three times more likely to develop thyroid cancer than men and at a slightly younger age (40 to 50 years old for women versus 60 to 70 for men).There may be a relationship between poorly controlled diabetes and an increased risk of thyroid cancer.There may be a genetic predisposition to thyroid cancer, especially in certain rare types of thyroid cancer.While smoking is associated with thyroid disease, worsening hypothyroidism and being a risk factor for Graves' disease, smoking does not appear to increase the risk of thyroid cancer.

Most often, a thyroid cancer is found when the patient or the patient's health care professional feels (palpates) a lump or nodule in the lower front of the neck where the thyroid is located. It is most often painless and found incidentally, by chance. Occasionally, an enlarged lymph node may be palpated by itself in the more lateral neck or in addition to a thyroid nodule.Most patients have normal thyroid function at the time the nodule is discovered and have no symptoms related to hyper or hypothyroidism.It the tumor grows locally, it may cause symptoms such as difficulty swallowing food (dysphagia) if it compresses the esophagus (which is rare) or hoarseness if the recurrent laryngeal nerve that is located near the thyroid gland -- which controls the vocal cords -- is invaded and causes vocal cord paralysis.In children, lumps in the neck are found frequently. Most often they are not in the thyroid gland itself. Aside from swollen lymph nodes associated with infections like pharyngitis, strep throat, or an ear infection (otitis media), lumps should not be ignored. In pediatric patients, thyroid cancer is the third most common solid tumor malignancy and the most common endocrine malignancy. The first sign might be a lump that is felt in the thyroid gland.

A thyroid nodule is an abnormal growth found within the thyroid gland. It may be solid, fluid filled (cystic) -- usually with a jelly like substance called colloid -- or a combination of both.Most often nodules are found incidentally when the patient or health care professional feels the neck. Whether the nodule is benign or cancerous cannot necessarily be determined just by feeling it and further tests may be warranted.

The exact cause of thyroid cancer is not known, though there are factors that may be associated with an increased risk of developing the cancer. Even if the risk factors are present, there is not a way of knowing whether cancer might develop; patients without risk factors still may develop thyroid cancer.

Research continues regarding the best treatment for the different types of thyroid cancers. New drugs are being developed that specifically target the thyroid cancer cells by attacking specific genes or proteins.MTC (medullary thyroid cancer) research and treatments include developing anti-cancer antibodies and attaching them to radioactive iodine to be injected into the body so that the combination molecule is taken up by the thyroid gland and then specifically attaches to and destroys cancer cells.Clinical trials continue to enroll patients with many diseases, including thyroid cancer. If appropriate, your health care professional may be a resource in finding a clinical trial that may be beneficial. Clinical trials that are enrolling patients can be found at the U.S. National Cancer Institute web site (https://www.cancer.gov/about-cancer/treatment/clinical-trials/search).

The recurrence rate of thyroid cancer depends upon whether the cancer remains localized within the thyroid gland or whether it has spread or metastasized to local structures in the neck or to distant sites in the body.In general, the recurrence risk of a cancer that has not spread is very low. For example, Italian researchers found that among patients with papillary cancer of the thyroid gland, those with a low risk of disease had a recurrence rate of about 1.4% at eight years.Researchers from the Mayo Clinic followed patients for up to 15 years and concluded that low risk patients had a recurrence rate of 3%-5%. However, they noted that more recently, thyroid cancer was being diagnosed much earlier and with the appropriate surgery, cure was much more likely and survival rate after surgery was very high.

Thyroid cancer is treated with a variety of therapies depending on the type and extent of cancer and the health of the patient.

There are many types of thyroid cancer, and outcome depends upon the type of thyroid cancer and its stage.Patients who have papillary or follicular cancer that is confined to the thyroid gland may expect a normal life expectancy with treatment. Prognosis may be better for women who are younger than 40 years of age.Patients with anaplastic cancer do poorly, with many surviving only a few months after diagnosis. The five-year survival rate for this cancer is less than 10%.

The thyroid gland is located in the front of the neck and is most well-known and responsible for producing thyroid hormone, the chemical in the body that is responsible for regulating the body's metabolism.Parafollicular cells in the thyroid produce the thyroid hormone. Too much thyroid production can cause hyperthyroidism (hyper=too much) where a person can experience rapid heartbeat and palpitations, sweating, heat intolerance, weight loss, and anxiety. Hypothyroidism (hypo=too little) may cause lethargy, weight gain, hair thinning, gravelly voice, and cold intolerance. The pituitary gland in the brain controls the amount of thyroid hormone that is produced by secreting thyroid stimulating hormone (TSH).C cells in the thyroid produce a hormone called calcitonin that helps to regulate calcium levels in the body.Other cells that are found in the thyroid include lymphocytes that are part of the body's immune system and stromal cells that help support the architecture of the thyroid gland itself.

Thyroid cancer affects up to 20,000 people in the U.S. every year but accounts for only 1% of new cancers that develop in the U.S. Thyroid cancer is the most common endocrine cancer.DNA (mutations) that occur spontaneously or in response to an environmental exposure or toxic substances can alter normal thyroid cells. The genetic changes cause the cells to multiply very rapidly without the normal controls found in the rest of the gland. Any of the cell types found in the thyroid gland can mutate into a specific type of cancer.Cancer is different than goiter, an enlargement of the thyroid gland that may be associated with hyper or hypothyroidism. Worldwide, the most common cause of goiter is iodine deficiency. In countries where table salt is iodinated, the autoimmune disease Hashimoto's thyroiditis, is the most common cause. Graves' disease, another autoimmune disease, can also be associated with thyroid enlargement.Research from the U.S. National Cancer Institute (NCI) has found that while the number of thyroid cancers being diagnosed has increased in the past 30 years, the death rate from thyroid cancer has remained the same. This suggests that there are not more cancers occurring but instead health care professionals and patients have become better at finding lumps in the thyroid gland and making the diagnosis.

Patients, families, and friends are all affected when the diagnosis of cancer is made. Support is available not only for the patient but for all those who are close to the patient. Hospitals, clinics, and health care professionals' offices often have specially trained staff to help patients and families address their physical, emotional, and spiritual needs.It is important for the patient and family to understand the disease, the treatment options, the expected outcomes, and the journey that will occur with cancer. It is important for all involved to advocate for the patient since there is so much information to understand and absorb; it can be overwhelming.There are many community resources available as well. The American Cancer Society is a good place to begin. They have local offices and may be contacted online.

A variety of physicians may be involved in the evaluation, diagnosis, and treatment of thyroid cancer. Primary care professionals may help coordinate care and may be the persons who make the initial diagnosis of thyroid gland abnormalities. Endocrinologists (physicians specializing in endocrine disorders) are specialists who specifically care for the thyroid. Surgeons may operate on the thyroid gland and thyroid cancer; these may be general surgeons or those with special training in head and neck surgery. Interventional radiologists may help with aspiration to obtain tissue samples, but this is also frequently performed by endocrinologists. Radiation oncologists, who are trained to provide radiation therapy treatments, may occasionally be asked to provide treatment. The care of thyroid cancer requires a team approach, but the members vary depending upon geographic location and availability of specialists.