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Surgical specimen of a
large goiter. Total thyroidectomy was performed because of the presence
of a solid nodule in the right lobe (note the size of the thyroid lobe at left of
the screen).
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Approach Considerations
The initial treatment for cancer of the thyroid is surgical. The exact nature
of the surgical procedure to be performed depends for the most part on the
extent of the local disease. A consensus approach might be to perform a
total thyroidectomy if the primary tumor is larger than 1 cm in diameter or if
there is extrathyroidal involvement or distant metastases. Clinically evident
lymphadenopathy should be removed with a neck dissection. If the primary
tumor is less than 1 cm in diameter, a unilateral lobectomy might be
considered.
Current National Comprehensive Cancer Network (NCCN) guidelines
recommend lobectomy plus isthmusectomy as the initial surgery for
patients with follicular neoplasms, with prompt completion of thyroidectomy
if invasive follicular thyroid carcinoma (FTC) is found on the final histologic
section. Therapeutic neck dissection of involved compartments is
recommended for clinically apparent/biopsy-proven disease. [1]
The NCCN recommends total thyroidectomy as the initial procedure only if
invasive cancer or metastatic disease is apparent at the time or surgery, or
if the patient wishes to avoid a second, completion thyroidectomy should
the pathologic review reveal cancer. [1]
About 4-6 weeks after surgical thyroid removal, patients must have
radioiodine to detect and destroy any metastasis and any residual tissue in
the thyroid. Administer therapy until no further radioiodine uptake is noted.
Patients take thyroid replacement therapy (ie, L-thyroxine [L-T4]) for life.
This entails taking 2.5-3.5 mcg/kg of L-T4 every day. The thyroxine is given
in the dose necessary to inhibit thyrotropin to a value of 0.1-0.5 mU/L. This
treatment plan is generally successful. However, a 10-year recurrence rate
of 20-30% may be seen in older patients, in patients with primary tumors
greater than 4 cm in diameter, and in patients where tumor has spread
beyond the thyroid boundaries and where lymph node involvement is
widespread. Once metastatic thyroid cancer becomes resistant to
radioiodine, the 10-year survival is less than 15%.
A number of indications for external beam radiation therapy (EBRT) apply
to the management of FTC.
If all gross disease cannot be resected, or if residual disease is not avid for
radioactive iodine, EBRT is often employed for locally advanced disease.
Similarly, radiation therapy is indicated for unresectable disease extending
into adjacent structures, such as the trachea, esophagus, great vessels,
mediastinum, and/or connective tissue. In this situation, radiation therapy
doses of 6000-6500 cGy are typically used. Following radiation therapy for
unresectable disease, the patient should undergo radioactive iodine (I-131)
scanning. If uptake is detected, a dose of I-131 should be administered.
EBRT increases the local-regional control of the residual disease for patients with
locally advanced differentiated thyroid carcinoma. [19] EBRT also may be used after
resection of recurrent FTC that is no longer avid for radioactive iodine.
In the postoperative setting, radiation therapy doses of 5000-6000 cGy are
commonly delivered to the tumor bed to reduce the risk of local-regional recurrence.
Careful treatment planning (typically with multiple radiation therapy fields) should be
employed to minimize the risks of radiation therapy complications.
Finally, a palliative course of radiation therapy is useful to relieve pain from bone
metastases.
Chemotherapy with cisplatin or doxorubicin has limited efficacy, producing
occasional objective responses (generally for short durations). Because of the high
toxicity of cisplatin and doxorubicin, chemotherapy may be considered in
symptomatic patients with recurrent or progressive disease. It could improve quality
of life in patients with bone metastases. No standard protocol exists for
chemotherapy of metastatic FTC.
FTC is a highly vascular lesion. In patients with bone metastases who experience
severe pain that does not respond to palliative radiation, arterial embolization of the
tumor might be considered.
The possible involvement of angiogenesis in the progression of metastatic thyroid
carcinoma has suggested a role for the multikinase inhibitor sunitinib, which may
inhibit angiogenesis. A phase II trial in 23 patients with advanced differentiated
thyroid cancer who had received at least one course of radioactive iodine treatment
demonstrated that sunitinib exhibits significant anti-tumor activity. Of the 23 patients,
six (26%) achieved a partial response and 13 (57%) had stab
When the primary tumor has spread outside the thyroid and involves adjacent vital
organs, such as the larynx, trachea, or esophagus, preserve these organs at the first
surgical approach. However, the surrounding soft tissues, including muscles and
involved areas of the trachea and/or esophagus, may be sacrificed whenever they
are involved directly in the differentiated thyroid carcinoma and their local resection
is easily feasible. Surgical resection of one or more brain metastases may prolong
survival from 4 to 22 months.
Minimally invasive techniques
During the last decade, a number of minimally invasive endoscopic approaches have
been proposed for the treatment of thyroid carcinoma, but these techniques may be
applied only to a small number of casesthose classified as 'low risk' carcinomas
according to the AGES and AMES classifications.
Robotic-assisted thyroidectomy
A study by Lee et al found that the application of robot technology to endoscopic
thyroidectomy may overcome the limitations of conventional surgery. [22]
The most useful drugs for postsurgical treatment of FTC are L-thyroxine (L-
T4) and radioiodine. Antineoplastic drugs such as cisplatin and doxorubicin
may be useful for palliation in patients with metastases.
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