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Thyroid Cancer

City of Hope’s comprehensive approach to thyroid cancer encompasses sophisticated diagnostic techniques and leading-edge surgical, radiotherapy and chemotherapy treatments for all types of thyroid cancers. City of Hope also employs new experimental therapies, which may not be available elsewhere, to fight advanced, aggressive thyroid cancers.

Thyroid cancer patients at City of Hope receive treatment from a coordinated, multidisciplinary team of surgeons, oncologists, endocrinologists, radiation oncologists, nurses, supportive care specialists and others, ensuring the highest possible standard of care.

About Thyroid Cancer
 
Thyroid cancer occurs when malignant cells in the thyroid proliferate uncontrollably, forming tumors. Typically, thyroid cancer, in its most frequently-occurring forms, has an excellent prognosis with very high five-year survival rates and many patients are cured outright. Other forms of the disease may be highly aggressive and less responsive to therapy.  Thyroid cancer has many forms, and there are significant differences between them in terms of risk factors, diagnostic tests and treatment options.

Understanding Your Thyroid
The thyroid is a small, butterfly-shaped gland located at the base of the throat near the trachea that produces thyroid hormones made by follicular cells. Thyroid hormones regulate metabolism and calcitonin, which is made by parafollicular cells, or C-cells. Calcitonin regulates the body’s calcium levels.  

Thyroid Hormone Levels: Too Much, Too Little and Just Right
Hypothyroidism refers to having too little thyroid hormone. If you are hypothyroid, your metabolism is slow, and you may experience weight gain, fatigue, depression, dry, itchy skin, dry, coarse and/or thinning hair, increased menstruation (heavier flow and/or more frequent periods), infertility and constipation. You feel generally sluggish, and may also feel cold frequently, particularly in the extremities.
Hyperthyroidism refers to an overactive thyroid, that is, one which produces too much thyroid hormone. The metabolism is abnormally fast and, as might be expected, the symptoms of hyperthyroidism are the polar opposite of hypothyroidism. They include: weight loss (despite a normal appetite), sweating, decreased menstruation, nervousness, insomnia, hand tremor, thinning skin, fine, thinning hair, rapid heartbeat and more frequent bowel movements or diarrhea.
When your thyroid hormone levels are normal, this is called euthyroid. Many patients diagnosed with thyroid cancer are euthyroid.

Nodules and Goiters
A thyroid nodule is a lump that develops in the thyroid. Depending on its size, it may be palpable or visible as a swelling in the neck. Most thyroid nodules are benign, but a small percentage are malignant.
The term “goiter” simply refers to an enlargement of the thyroid, which may be diffuse or nodular. Many goiters are multinodular as opposed to a solitary nodule. Goiters can occur in hyperthyroid, hypothyroid and euthyroid patients and generally develop as a result of increased TSH levels. 

Types of Thyroid Cancer 
 
  • Papillary thyroid cancer is the most common type of thyroid cancer, accounting for over 80 percent of cases. It is usually slow-growing, localized to the thyroid, well-differentiated and has an excellent prognosis with high survival rates.
  • Follicular thyroid cancer, as the name implies, originates from follicular cells. It is also usually slow-growing, localized to the thyroid. Follicular thyroid carcinoma has a good prognosis with high survival rates. 
  • Hurthle cell cancer is a type of follicular carcinoma in which a specific kind of cell (the Hurthle cell) is predominant in the tumor. Hurthle cell cancers are slightly more aggressive than other follicular carcinomas. They are less likely to take up radioiodine, which is significant because radioiodine ablates (destroys) residual thyroid tissue, and is thus an important treatment modality. They are also more likely to have nodal metastases (spread to neighboring lymph nodes). 
  • Anaplastic thyroid cancer is a type of follicular carcinoma that is thought to originate from well-differentiated papillary or follicular cancers through a process called dedifferentiation.
  • Medullary thyroid cancer develops in the C-cells of the thyroid. More than any other type of thyroid cancer, medullary thyroid cancer has a well-established genetic component, with a sizable proportion of cases thought to be an inherited form of the disease. 
  • Thyroid lymphoma cancer originates from lymphoid tissue in the thyroid (as opposed to carcinomas, described above, which develop from epithelial cells). It is very rare, and often develops in patients who have a history of chronic thyroiditis. It is often treated similarly to other forms of non-Hodgkin lymphoma.
 
Thyroid Cancer Risk Factors
 
  • Age and Sex: Patients with thyroid cancer are more likely to be female (three times more likely than males) and over 45 years of age. Anaplastic thyroid cancer almost always occurs in patients over 60. In evaluating whether a thyroid nodule may be malignant, a malignant nodule is much more likely if the patient is male and under the age of 20.
  • Race: Caucasians are more likely than African-Americans to develop thyroid cancer.
  • Childbearing Age: Women who have their last pregnancy after age 30 are at higher risk.
  • Previous goiter/benign thyroid nodule
  • Family history of medullary thyroid cancer (either FMTC or the MEN syndromes)
  • Family history of multinodular goiter
  • Family history of colon growths (Gardner’s syndrome/familial adenomatous polyposis, or FAP)
  • Having Cowden’s disease (a rare inherited disorder)
  • Iodine deficiency or excessive iodine intake
  • Radiation exposure: this can be from prior radiotherapy treatment for other forms of cancer, exposure to atomic testing or nuclear power plant accidents or other occupational exposure. In addition, doctors used to routinely administer X-ray treatment to the head and neck area for conditions such as acne, fungal infections of the scalp and enlarged tonsils. This also was a significant cause of unnecessary radiation exposure.
 
Thyroid Cancer Symptoms
 
Often, thyroid cancer in its early stages does not exhibit symptoms. Many cases are found on routine examination as part of a physical. Your doctor may palpate, or feel, the area around the front of your neck, and may ask you to swallow some water as he or she is doing this. This allows for detection of any enlargement or mass in the thyroid.
 
The following represent symptoms typical of thyroid cancer:
 
  • A lump in the front of the neck
  • Hoarseness or voice changes
  • Swollen lymph nodes in the neck
  • Trouble swallowing or breathing
  • Pain in the throat or neck that does not go away
  • Persistent cough; coughing up blood

Patients with medullary thyroid cancer may also experience (in addition to the foregoing):
 
  • Diarrhea
  • Facial flushing/redness

These symptoms are due to increased levels of calcitonin common in this form of thyroid cancer.
 

Diagnosing Thyroid Cancer

Neck Palpation
This simple test, which involves your doctor feeling the area around the front of your neck, is often how thyroid cancer is initially diagnosed. Most thyroid cancers can be felt as a single, hard nodule.

Ultrasound
If your doctor feels a nodule by palpating your neck, he may suggest an ultrasound. This simple, quick and painless test passes a wand, called a transducer, which emits sound waves, over the thyroid gland to produce an image. Based on this image, your doctor can determine the exact size and shape of the nodule, if the nodule is filled with fluid, or if there is a blood supply to the nodule. Small nodules (under ¾ inch or 1.5 centimeters) with regular borders are often benign, whereas larger nodules with irregularly-shaped borders have a greater chance of being malignant.
 
Cysts, which are fluid-filled, are usually benign, whereas solid nodules may be malignant. However, it is important to understand that an ultrasound showing a solid nodule is not sufficient to establish a diagnosis of thyroid cancer. This is because most solid nodules are benign. Nodules may be partially cystic or partially solid, and in either circumstance, may be benign or malignant.

Radioiodine Scan
In this test, your doctor will have you drink a solution containing the radioactive isotope iodine-131. Because thyroid cells use iodine to make thyroid hormone, the iodine-131 will be taken up by and concentrated in the thyroid gland. The radioiodine emits gamma rays. These gamma rays are counted and turned into an image by a “gamma camera” in a process known as scintigraphy. The gamma camera is placed at the neck to determine how much radioactivity is being emitted by the thyroid gland, and areas in which the radioactivity may be particularly high or low.

If a thyroid nodule takes up less radioiodine than surrounding thyroid tissue, it is called a cold nodule.

If a thyroid nodule takes up more radioiodine than surrounding thyroid tissue, it is then a hot nodule.

Hot nodules are not likely to be thyroid cancer. However, a cold nodule may be either benign or malignant.

Whole-body radioiodine scans may be useful in detecting metastases of thyroid cancer, because any thyroid-derived tissue, anywhere in the body, will show up on the scan. These scans are also frequently used to monitor a patient’s response to therapy. This technique is only useful in well-differentiated forms of thyroid cancer, such as papillary or follicular thyroid cancer, as they readily take up radioiodine. Poorly-differentiated forms of these cancers, as well as medullary or anaplastic thyroid cancers, do not take up radioiodine, and the scan therefore has no diagnostic value.

Positron Emission Tomography Scans
Posititron emission tomography (PET) scans use a modified sugar compound called fluorodeoxyglucose (FDG). The scan picks up areas of cells that preferentially absorb the FDG. PET scans may be useful with tumors that do not take up radioiodine, such as poorly-differentiated papillary and follicular thyroid cancers, in order to monitor for possible recurrence. In medullary thyroid cancer, a PET scan is not considered as sensitive as an octreotide scan, and is thus not the preferred test.

Biopsy
The gold standard in diagnosing thyroid cancer is fine-needle aspiration biopsy (FNAB). In this test, a topical anesthetic, such as ethyl chloride, is first applied to the neck area. Sometimes, your doctor may inject a local anesthetic.
The material collected from the FNAB is then sent to a pathology laboratory. The pathologist examines the thyroid cells under a microscope for certain defining characteristics of malignancy.

Blood Tests

Thyroglobulin
This test measures thyroglobulin, a protein produced by the thyroid. It may be elevated in thyroid cancer. Testing for thyroglobulin is not used to establish a diagnosis of thyroid cancer, as many conditions may cause elevated thyroglobulin levels.
The test is used most often to check for recurrence or metastasis after surgical removal of the thyroid and radioiodine ablation (destruction of residual thyroid tissue). This is because after these treatments, there should be hardly any thyroid cells left to produce thyroglobulin, so if elevated levels are seen, it suggests that they have not been sufficiently eradicated, and the disease may have recurred and/or metastasized.

Thyroid stimulating hormone
This test measures blood levels of thyroid stimulating hormone (TSH) produced by the pituitary gland. TSH levels may be higher in patients with thyroid cancer. Just as with thyroglobulin, this is not diagnostic of thyroid cancer.

The importance of testing for TSH generally comes after the patient is treated for thyroid cancer with a thyroidectomy and radioiodine ablation. These patients are generally treated with T4 (thyroxine) in order to suppress TSH levels. High levels of TSH may stimulate thyroid tumor growth. Therefore, TSH suppression to a very low level should help reduce tumor growth and lessen the chance of recurrence or metastasis. Hence, your physician will regularly monitor your TSH blood levels to make sure the suppression therapy is working.

Calcitonin test
This test is used in patients with suspected medullary thyroid cancer. Because medullary thyroid cancer occurs in the C-cells of the thyroid, which produce the hormone calcitonin, increased calcitonin levels may be indicative of the disease. Very high levels of calcitonin are suggestive of advanced disease.

Carcinoembryonic antigen test
This is a blood test for carcinoembryonic antigen (CEA). CEA is produced by medullary thyroid cancer cells, so determining CEA levels may indicate the extent of the disease. This test is not diagnostic with other thyroid cancers.
 

Staging

Staging is the process of finding out if and how far a cancer has spread. The stage of a cancer is one of the most important factors in choosing treatment options and predicting your chance for cure and long-term survival.

Staging is based on the results of the physical exam, biopsy and imaging tests (ultrasound, computed tomography scan, magnetic resonance imaging, chest X-ray and/or radioisotope scans)

Unlike most other cancers, thyroid cancers are grouped into stages in a way that considers both the subtype of cancer and the patient's age.

Stage Grouping for Papillary or Follicular Thyroid Carcinoma (Differentiated Thyroid Cancer)

Younger people have a low likelihood of dying from differentiated (papillary or follicular) thyroid cancer. The stage groupings for these cancers take this fact into account. So, all people younger than 45 years with papillary thyroid cancer, for example, are stage I if they have no distant spread and stage II if they have distant metastases beyond the neck or upper mediastinal lymph nodes.

Patients younger than 45 years:
  • Stage I:  The tumor can be any size and may or may not have spread to nearby lymph nodes. It has not spread to distant sites.
  • Stage II:  The tumor can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant sites.

Patients 45 years and older:
  • Stage I:  The tumor is less than 2 cm across and has not spread to nearby lymph nodes or distant sites.
  • Stage II:  The tumor is 2 to 4 cm across and has not spread to nearby lymph nodes or distant sites.
  • Stage III:  One of the following applies:
The tumor is larger than 4 cm or has grown slightly outside the thyroid, but it has not spread to nearby lymph nodes or distant sites. The tumor is any size and has spread to lymph nodes around the thyroid in the neck (cervical nodes) but not to distant sites.
  • Stage IVA:  One of the following applies:
The tumor is any size and has grown beyond the thyroid gland to invade nearby tissues of the neck. It may or may not have spread to lymph nodes around the thyroid in the neck (cervical nodes). It has not spread to distant sites. The tumor is any size and may have grown outside of the thyroid gland. It has spread to lymph nodes in the side of the neck (lateral cervical nodes) or upper chest (upper mediastinal nodes) but not to distant sites.
  • Stage IVB:  The tumor is any size and has grown either back to the spine or into nearby large blood vessels. It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVC:  The tumor is any size and may or may not have grown outside the thyroid. It may or may not have spread to nearby lymph nodes. It has spread to distant sites.

Stage Grouping for Medullary Thyroid Carcinoma

Stage grouping for medullary thyroid carcinoma in people of any age is the same as for papillary or follicular carcinoma in people older than age 45.

Stage Grouping for Anaplastic/Undifferentiated Thyroid Carcinoma

All anaplastic thyroid cancers are considered stage IV, reflecting the poor prognosis of this type of cancer.
  • Stage IVA:  Tumor is still within the thyroid and may be resectable (removable by surgery). It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVB:  Tumor has grown outside of the thyroid and is not resectable. It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVC:  The tumor is any size and may or may not have grown outside of the thyroid. It may or may not have spread to nearby lymph nodes. It has spread to distant sites.
 

Thyroid Cancer Treatment Options

Surgery
First-line treatment for thyroid cancer is surgery. The procedure performed is usually a total thyroidectomy, where the entire thyroid is removed, or a subtotal thyroidectomy, where nearly the entire thyroid is removed except for a small amount of tissue. During surgery, the lymph nodes are examined and may be removed if cancerous. In medullary thyroid cancer, in addition to total thyroidectomy, a central neck dissection (removal of all lymph nodes and fatty tissues in the central neck area) is usually performed.

In many cases of well-differentiated, localized thyroid cancer, thyroidectomy affords an excellent chance of cure or long-term survival. It should be noted that radioiodine therapy (discussed below) is usually given to destroy any residual thyroid cancer cells that may remain after thyroidectomy.
Regular follow-up visits, which will include diagnostic scans, are important to detect any recurrence.

 

Radioiodine Therapy
Radioiodine therapy destroys residual thyroid cancer cells that may be present after surgical removal of the thyroid. This is important because such residual cells are common in many cases of thyroid cancer. Radioiodine therapy also destroys noncancerous thyroid tissue, creating what is known as an athyroidal state. Destroying even noncancerous residual thyroid tissue is helpful because residual tissue will take up radioiodine in a scan, making it more difficult to visualize thyroid cancer sites during follow-up imaging scans. Residual thyroid tissue also produces thyroglobulin, so the use of thyroglobulin as a tumor marker in follow-up is less valuable.

Radioiodine therapy can cause side effects such as sore throat, nausea, vomiting and dry mouth. Depending on the amount of radiation to be administered, isolation may be necessary to protect family and friends from exposure.

 

Thyroid Hormone Replacement
Because radioiodine therapy destroys thyroid tissue, there is no mechanism for the body to produce thyroid hormone (thyroxine), which is essential. Thyroxine is prescribed and must be taken daily. Not only does this prevent hypothyroidism, it also suppresses thyroid stimulating hormone (TSH) levels. Suppression of TSH is thought to reduce the chance of thyroid tumor growth.

Preparing for Radioiodine Therapy or Follow-up Radioiodine Scan

In order to obtain optimal results (high radioiodine uptake) from your radioiodine therapy, you need to have high blood levels of TSH. This normally would entail stopping daily thyroxine therapy for a period of time. Unfortunately, the hypothyroid state this induces is uncomfortable. Until recently, this was the only practical way to raise TSH in preparation for a scan.

 

Today, another option is available. Thyrogen, a brand of recombinant TSH, can now be administered to patients to raise their TSH levels in preparation for their radioiodine scans or radiotherapy. Patients can continue their normal daily thyroxine therapy throughout the process.

 

External Beam Radiation Therapy
In thyroid cancers that do not take up radioiodine, and in advanced cases where surgery is not an option, or in recurrent thyroid cancers, external beam radiation therapy may be used. Here, an external source of radiation (a machine) is used to deliver radioactivity to the thyroid. A high dose of radiation is employed to destroy thyroid cancer cells.
Patients may experience side effects such as sore throat, hoarseness, difficulty in swallowing and dry mouth.

 

Chemotherapy
Chemotherapy is used in thyroid cancers that have metastasized and/or thyroid cancers that do not respond to radioiodine therapy. Usually a combination of drugs is administered.

New Approaches in Chemotherapy

 

Redifferentiation
The more troublesome and aggressive types of thyroid cancer are poorly differentiated or undifferentiated. Because they cannot take up radioiodine, a very powerful therapeutic modality is therefore unavailable. A novel strategy, called redifferentiation, has been under investigation recently, and shows significant promise. The premise of this approach is that certain compounds can redifferentiate the poorly-differentiated cells, making them now able to concentrate radioiodine.

 

Radioimmunotherapy
Radioimmunotherapy has produced encouraging results in medullary thyroid cancer. Because this type of thyroid cancer produces carcinoembryonic antigen (CEA), the cancer cells can be targeted using a radiolabeled antibody called anti-CEA.

 

Clinical Trials
City of Hope has several clinical trials involving experimental therapies for advanced solid tumors, including thyroid cancer.  Click here for more information.

 

 

Thyroid Cancer Resources

All of our thyroid cancer patients also have access to the Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs.

ThyCa: Thyroid Cancer Survivors’ Association Inc.
P.O. Box 1545
New York, NY 10159-1545
Phone: 877-588-7904
Fax: 630-604-6078
ThyCa is a nonprofit organization developing programs to link survivors and health-care professionals around the world. Their Web site maintains current information about thyroid cancer and support services available to people at any stage of testing, treatment or lifelong monitoring for thyroid cancer, as well as their caregivers. It receives ongoing input and review from numerous thyroid cancer specialists. The site also serves as a resource for anyone interested in thyroid cancer survivors' issues, and includes news for survivors about online chats, conferences, mailing lists and local support groups.
www.thyca.org

EndocrineWeb
EndocrineWeb is a comprehensive Web site for thyroid, parathyroid and other endocrine disorders intended for the education of patients and their families. All pages were written by physicians who treat these diseases.
www.endocrineweb.com

American Thyroid Association
6066 Leesburg Pike, Suite 550
Falls Church, VA 22041
Phone: 703-998-8890
Fax: 703-998-8893
The American Thyroid Association (ATA) is the leading organization focused on thyroid biology and the prevention and treatment of thyroid disorders through excellence and innovation in research, clinical care, education and public health. The ATA Web site features a variety of FAQs and brochures for patients.
www.thyroid.org/patients/index.html

American Cancer Society
Phone: 800-ACS-2345
For TYY: 866-228-4327
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.
www.cancer.org

National Comprehensive Cancer Network
Phone: 888-909- NCCN (6226)
The National Comprehensive Cancer Network, an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
www.nccn.org

National Cancer Institute
Phone: 800-4-CANCER
The National Cancer Institute, established under the National Cancer Act of 1937, is the federal government's principal agency for cancer research and training.
www.cancer.gov

U.S. Dept. of Health and Human Services
National Institutes of Health
Phone: 301-496-4000
For TYY: 301-402-9612
The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health and Human Services.
www.nih.gov
 

Thyroid Cancer Team

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It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact us below.

Kimberly Wah
Director
Phone: 213-241-7275
Email: kwah@coh.org

 
 

Thyroid Cancer

Thyroid Cancer

City of Hope’s comprehensive approach to thyroid cancer encompasses sophisticated diagnostic techniques and leading-edge surgical, radiotherapy and chemotherapy treatments for all types of thyroid cancers. City of Hope also employs new experimental therapies, which may not be available elsewhere, to fight advanced, aggressive thyroid cancers.

Thyroid cancer patients at City of Hope receive treatment from a coordinated, multidisciplinary team of surgeons, oncologists, endocrinologists, radiation oncologists, nurses, supportive care specialists and others, ensuring the highest possible standard of care.

About Thyroid Cancer
 
Thyroid cancer occurs when malignant cells in the thyroid proliferate uncontrollably, forming tumors. Typically, thyroid cancer, in its most frequently-occurring forms, has an excellent prognosis with very high five-year survival rates and many patients are cured outright. Other forms of the disease may be highly aggressive and less responsive to therapy.  Thyroid cancer has many forms, and there are significant differences between them in terms of risk factors, diagnostic tests and treatment options.

Understanding Your Thyroid
The thyroid is a small, butterfly-shaped gland located at the base of the throat near the trachea that produces thyroid hormones made by follicular cells. Thyroid hormones regulate metabolism and calcitonin, which is made by parafollicular cells, or C-cells. Calcitonin regulates the body’s calcium levels.  

Thyroid Hormone Levels: Too Much, Too Little and Just Right
Hypothyroidism refers to having too little thyroid hormone. If you are hypothyroid, your metabolism is slow, and you may experience weight gain, fatigue, depression, dry, itchy skin, dry, coarse and/or thinning hair, increased menstruation (heavier flow and/or more frequent periods), infertility and constipation. You feel generally sluggish, and may also feel cold frequently, particularly in the extremities.
Hyperthyroidism refers to an overactive thyroid, that is, one which produces too much thyroid hormone. The metabolism is abnormally fast and, as might be expected, the symptoms of hyperthyroidism are the polar opposite of hypothyroidism. They include: weight loss (despite a normal appetite), sweating, decreased menstruation, nervousness, insomnia, hand tremor, thinning skin, fine, thinning hair, rapid heartbeat and more frequent bowel movements or diarrhea.
When your thyroid hormone levels are normal, this is called euthyroid. Many patients diagnosed with thyroid cancer are euthyroid.

Nodules and Goiters
A thyroid nodule is a lump that develops in the thyroid. Depending on its size, it may be palpable or visible as a swelling in the neck. Most thyroid nodules are benign, but a small percentage are malignant.
The term “goiter” simply refers to an enlargement of the thyroid, which may be diffuse or nodular. Many goiters are multinodular as opposed to a solitary nodule. Goiters can occur in hyperthyroid, hypothyroid and euthyroid patients and generally develop as a result of increased TSH levels. 

Types of Thyroid Cancer 
 
  • Papillary thyroid cancer is the most common type of thyroid cancer, accounting for over 80 percent of cases. It is usually slow-growing, localized to the thyroid, well-differentiated and has an excellent prognosis with high survival rates.
  • Follicular thyroid cancer, as the name implies, originates from follicular cells. It is also usually slow-growing, localized to the thyroid. Follicular thyroid carcinoma has a good prognosis with high survival rates. 
  • Hurthle cell cancer is a type of follicular carcinoma in which a specific kind of cell (the Hurthle cell) is predominant in the tumor. Hurthle cell cancers are slightly more aggressive than other follicular carcinomas. They are less likely to take up radioiodine, which is significant because radioiodine ablates (destroys) residual thyroid tissue, and is thus an important treatment modality. They are also more likely to have nodal metastases (spread to neighboring lymph nodes). 
  • Anaplastic thyroid cancer is a type of follicular carcinoma that is thought to originate from well-differentiated papillary or follicular cancers through a process called dedifferentiation.
  • Medullary thyroid cancer develops in the C-cells of the thyroid. More than any other type of thyroid cancer, medullary thyroid cancer has a well-established genetic component, with a sizable proportion of cases thought to be an inherited form of the disease. 
  • Thyroid lymphoma cancer originates from lymphoid tissue in the thyroid (as opposed to carcinomas, described above, which develop from epithelial cells). It is very rare, and often develops in patients who have a history of chronic thyroiditis. It is often treated similarly to other forms of non-Hodgkin lymphoma.
 
Thyroid Cancer Risk Factors
 
  • Age and Sex: Patients with thyroid cancer are more likely to be female (three times more likely than males) and over 45 years of age. Anaplastic thyroid cancer almost always occurs in patients over 60. In evaluating whether a thyroid nodule may be malignant, a malignant nodule is much more likely if the patient is male and under the age of 20.
  • Race: Caucasians are more likely than African-Americans to develop thyroid cancer.
  • Childbearing Age: Women who have their last pregnancy after age 30 are at higher risk.
  • Previous goiter/benign thyroid nodule
  • Family history of medullary thyroid cancer (either FMTC or the MEN syndromes)
  • Family history of multinodular goiter
  • Family history of colon growths (Gardner’s syndrome/familial adenomatous polyposis, or FAP)
  • Having Cowden’s disease (a rare inherited disorder)
  • Iodine deficiency or excessive iodine intake
  • Radiation exposure: this can be from prior radiotherapy treatment for other forms of cancer, exposure to atomic testing or nuclear power plant accidents or other occupational exposure. In addition, doctors used to routinely administer X-ray treatment to the head and neck area for conditions such as acne, fungal infections of the scalp and enlarged tonsils. This also was a significant cause of unnecessary radiation exposure.
 
Thyroid Cancer Symptoms
 
Often, thyroid cancer in its early stages does not exhibit symptoms. Many cases are found on routine examination as part of a physical. Your doctor may palpate, or feel, the area around the front of your neck, and may ask you to swallow some water as he or she is doing this. This allows for detection of any enlargement or mass in the thyroid.
 
The following represent symptoms typical of thyroid cancer:
 
  • A lump in the front of the neck
  • Hoarseness or voice changes
  • Swollen lymph nodes in the neck
  • Trouble swallowing or breathing
  • Pain in the throat or neck that does not go away
  • Persistent cough; coughing up blood

Patients with medullary thyroid cancer may also experience (in addition to the foregoing):
 
  • Diarrhea
  • Facial flushing/redness

These symptoms are due to increased levels of calcitonin common in this form of thyroid cancer.
 

Diagnosing Thyroid Cancer

Diagnosing Thyroid Cancer

Neck Palpation
This simple test, which involves your doctor feeling the area around the front of your neck, is often how thyroid cancer is initially diagnosed. Most thyroid cancers can be felt as a single, hard nodule.

Ultrasound
If your doctor feels a nodule by palpating your neck, he may suggest an ultrasound. This simple, quick and painless test passes a wand, called a transducer, which emits sound waves, over the thyroid gland to produce an image. Based on this image, your doctor can determine the exact size and shape of the nodule, if the nodule is filled with fluid, or if there is a blood supply to the nodule. Small nodules (under ¾ inch or 1.5 centimeters) with regular borders are often benign, whereas larger nodules with irregularly-shaped borders have a greater chance of being malignant.
 
Cysts, which are fluid-filled, are usually benign, whereas solid nodules may be malignant. However, it is important to understand that an ultrasound showing a solid nodule is not sufficient to establish a diagnosis of thyroid cancer. This is because most solid nodules are benign. Nodules may be partially cystic or partially solid, and in either circumstance, may be benign or malignant.

Radioiodine Scan
In this test, your doctor will have you drink a solution containing the radioactive isotope iodine-131. Because thyroid cells use iodine to make thyroid hormone, the iodine-131 will be taken up by and concentrated in the thyroid gland. The radioiodine emits gamma rays. These gamma rays are counted and turned into an image by a “gamma camera” in a process known as scintigraphy. The gamma camera is placed at the neck to determine how much radioactivity is being emitted by the thyroid gland, and areas in which the radioactivity may be particularly high or low.

If a thyroid nodule takes up less radioiodine than surrounding thyroid tissue, it is called a cold nodule.

If a thyroid nodule takes up more radioiodine than surrounding thyroid tissue, it is then a hot nodule.

Hot nodules are not likely to be thyroid cancer. However, a cold nodule may be either benign or malignant.

Whole-body radioiodine scans may be useful in detecting metastases of thyroid cancer, because any thyroid-derived tissue, anywhere in the body, will show up on the scan. These scans are also frequently used to monitor a patient’s response to therapy. This technique is only useful in well-differentiated forms of thyroid cancer, such as papillary or follicular thyroid cancer, as they readily take up radioiodine. Poorly-differentiated forms of these cancers, as well as medullary or anaplastic thyroid cancers, do not take up radioiodine, and the scan therefore has no diagnostic value.

Positron Emission Tomography Scans
Posititron emission tomography (PET) scans use a modified sugar compound called fluorodeoxyglucose (FDG). The scan picks up areas of cells that preferentially absorb the FDG. PET scans may be useful with tumors that do not take up radioiodine, such as poorly-differentiated papillary and follicular thyroid cancers, in order to monitor for possible recurrence. In medullary thyroid cancer, a PET scan is not considered as sensitive as an octreotide scan, and is thus not the preferred test.

Biopsy
The gold standard in diagnosing thyroid cancer is fine-needle aspiration biopsy (FNAB). In this test, a topical anesthetic, such as ethyl chloride, is first applied to the neck area. Sometimes, your doctor may inject a local anesthetic.
The material collected from the FNAB is then sent to a pathology laboratory. The pathologist examines the thyroid cells under a microscope for certain defining characteristics of malignancy.

Blood Tests

Thyroglobulin
This test measures thyroglobulin, a protein produced by the thyroid. It may be elevated in thyroid cancer. Testing for thyroglobulin is not used to establish a diagnosis of thyroid cancer, as many conditions may cause elevated thyroglobulin levels.
The test is used most often to check for recurrence or metastasis after surgical removal of the thyroid and radioiodine ablation (destruction of residual thyroid tissue). This is because after these treatments, there should be hardly any thyroid cells left to produce thyroglobulin, so if elevated levels are seen, it suggests that they have not been sufficiently eradicated, and the disease may have recurred and/or metastasized.

Thyroid stimulating hormone
This test measures blood levels of thyroid stimulating hormone (TSH) produced by the pituitary gland. TSH levels may be higher in patients with thyroid cancer. Just as with thyroglobulin, this is not diagnostic of thyroid cancer.

The importance of testing for TSH generally comes after the patient is treated for thyroid cancer with a thyroidectomy and radioiodine ablation. These patients are generally treated with T4 (thyroxine) in order to suppress TSH levels. High levels of TSH may stimulate thyroid tumor growth. Therefore, TSH suppression to a very low level should help reduce tumor growth and lessen the chance of recurrence or metastasis. Hence, your physician will regularly monitor your TSH blood levels to make sure the suppression therapy is working.

Calcitonin test
This test is used in patients with suspected medullary thyroid cancer. Because medullary thyroid cancer occurs in the C-cells of the thyroid, which produce the hormone calcitonin, increased calcitonin levels may be indicative of the disease. Very high levels of calcitonin are suggestive of advanced disease.

Carcinoembryonic antigen test
This is a blood test for carcinoembryonic antigen (CEA). CEA is produced by medullary thyroid cancer cells, so determining CEA levels may indicate the extent of the disease. This test is not diagnostic with other thyroid cancers.
 

Staging

Staging

Staging is the process of finding out if and how far a cancer has spread. The stage of a cancer is one of the most important factors in choosing treatment options and predicting your chance for cure and long-term survival.

Staging is based on the results of the physical exam, biopsy and imaging tests (ultrasound, computed tomography scan, magnetic resonance imaging, chest X-ray and/or radioisotope scans)

Unlike most other cancers, thyroid cancers are grouped into stages in a way that considers both the subtype of cancer and the patient's age.

Stage Grouping for Papillary or Follicular Thyroid Carcinoma (Differentiated Thyroid Cancer)

Younger people have a low likelihood of dying from differentiated (papillary or follicular) thyroid cancer. The stage groupings for these cancers take this fact into account. So, all people younger than 45 years with papillary thyroid cancer, for example, are stage I if they have no distant spread and stage II if they have distant metastases beyond the neck or upper mediastinal lymph nodes.

Patients younger than 45 years:
  • Stage I:  The tumor can be any size and may or may not have spread to nearby lymph nodes. It has not spread to distant sites.
  • Stage II:  The tumor can be any size and may or may not have spread to nearby lymph nodes. It has spread to distant sites.

Patients 45 years and older:
  • Stage I:  The tumor is less than 2 cm across and has not spread to nearby lymph nodes or distant sites.
  • Stage II:  The tumor is 2 to 4 cm across and has not spread to nearby lymph nodes or distant sites.
  • Stage III:  One of the following applies:
The tumor is larger than 4 cm or has grown slightly outside the thyroid, but it has not spread to nearby lymph nodes or distant sites. The tumor is any size and has spread to lymph nodes around the thyroid in the neck (cervical nodes) but not to distant sites.
  • Stage IVA:  One of the following applies:
The tumor is any size and has grown beyond the thyroid gland to invade nearby tissues of the neck. It may or may not have spread to lymph nodes around the thyroid in the neck (cervical nodes). It has not spread to distant sites. The tumor is any size and may have grown outside of the thyroid gland. It has spread to lymph nodes in the side of the neck (lateral cervical nodes) or upper chest (upper mediastinal nodes) but not to distant sites.
  • Stage IVB:  The tumor is any size and has grown either back to the spine or into nearby large blood vessels. It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVC:  The tumor is any size and may or may not have grown outside the thyroid. It may or may not have spread to nearby lymph nodes. It has spread to distant sites.

Stage Grouping for Medullary Thyroid Carcinoma

Stage grouping for medullary thyroid carcinoma in people of any age is the same as for papillary or follicular carcinoma in people older than age 45.

Stage Grouping for Anaplastic/Undifferentiated Thyroid Carcinoma

All anaplastic thyroid cancers are considered stage IV, reflecting the poor prognosis of this type of cancer.
  • Stage IVA:  Tumor is still within the thyroid and may be resectable (removable by surgery). It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVB:  Tumor has grown outside of the thyroid and is not resectable. It may or may not have spread to nearby lymph nodes, but it has not spread to distant sites.
  • Stage IVC:  The tumor is any size and may or may not have grown outside of the thyroid. It may or may not have spread to nearby lymph nodes. It has spread to distant sites.
 

Thyroid Cancer Treatment Options

Thyroid Cancer Treatment Options

Surgery
First-line treatment for thyroid cancer is surgery. The procedure performed is usually a total thyroidectomy, where the entire thyroid is removed, or a subtotal thyroidectomy, where nearly the entire thyroid is removed except for a small amount of tissue. During surgery, the lymph nodes are examined and may be removed if cancerous. In medullary thyroid cancer, in addition to total thyroidectomy, a central neck dissection (removal of all lymph nodes and fatty tissues in the central neck area) is usually performed.

In many cases of well-differentiated, localized thyroid cancer, thyroidectomy affords an excellent chance of cure or long-term survival. It should be noted that radioiodine therapy (discussed below) is usually given to destroy any residual thyroid cancer cells that may remain after thyroidectomy.
Regular follow-up visits, which will include diagnostic scans, are important to detect any recurrence.

 

Radioiodine Therapy
Radioiodine therapy destroys residual thyroid cancer cells that may be present after surgical removal of the thyroid. This is important because such residual cells are common in many cases of thyroid cancer. Radioiodine therapy also destroys noncancerous thyroid tissue, creating what is known as an athyroidal state. Destroying even noncancerous residual thyroid tissue is helpful because residual tissue will take up radioiodine in a scan, making it more difficult to visualize thyroid cancer sites during follow-up imaging scans. Residual thyroid tissue also produces thyroglobulin, so the use of thyroglobulin as a tumor marker in follow-up is less valuable.

Radioiodine therapy can cause side effects such as sore throat, nausea, vomiting and dry mouth. Depending on the amount of radiation to be administered, isolation may be necessary to protect family and friends from exposure.

 

Thyroid Hormone Replacement
Because radioiodine therapy destroys thyroid tissue, there is no mechanism for the body to produce thyroid hormone (thyroxine), which is essential. Thyroxine is prescribed and must be taken daily. Not only does this prevent hypothyroidism, it also suppresses thyroid stimulating hormone (TSH) levels. Suppression of TSH is thought to reduce the chance of thyroid tumor growth.

Preparing for Radioiodine Therapy or Follow-up Radioiodine Scan

In order to obtain optimal results (high radioiodine uptake) from your radioiodine therapy, you need to have high blood levels of TSH. This normally would entail stopping daily thyroxine therapy for a period of time. Unfortunately, the hypothyroid state this induces is uncomfortable. Until recently, this was the only practical way to raise TSH in preparation for a scan.

 

Today, another option is available. Thyrogen, a brand of recombinant TSH, can now be administered to patients to raise their TSH levels in preparation for their radioiodine scans or radiotherapy. Patients can continue their normal daily thyroxine therapy throughout the process.

 

External Beam Radiation Therapy
In thyroid cancers that do not take up radioiodine, and in advanced cases where surgery is not an option, or in recurrent thyroid cancers, external beam radiation therapy may be used. Here, an external source of radiation (a machine) is used to deliver radioactivity to the thyroid. A high dose of radiation is employed to destroy thyroid cancer cells.
Patients may experience side effects such as sore throat, hoarseness, difficulty in swallowing and dry mouth.

 

Chemotherapy
Chemotherapy is used in thyroid cancers that have metastasized and/or thyroid cancers that do not respond to radioiodine therapy. Usually a combination of drugs is administered.

New Approaches in Chemotherapy

 

Redifferentiation
The more troublesome and aggressive types of thyroid cancer are poorly differentiated or undifferentiated. Because they cannot take up radioiodine, a very powerful therapeutic modality is therefore unavailable. A novel strategy, called redifferentiation, has been under investigation recently, and shows significant promise. The premise of this approach is that certain compounds can redifferentiate the poorly-differentiated cells, making them now able to concentrate radioiodine.

 

Radioimmunotherapy
Radioimmunotherapy has produced encouraging results in medullary thyroid cancer. Because this type of thyroid cancer produces carcinoembryonic antigen (CEA), the cancer cells can be targeted using a radiolabeled antibody called anti-CEA.

 

Clinical Trials
City of Hope has several clinical trials involving experimental therapies for advanced solid tumors, including thyroid cancer.  Click here for more information.

 

 

Additional Resources

Thyroid Cancer Resources

All of our thyroid cancer patients also have access to the Sheri & Les Biller Patient and Family Resource Center, which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs.

ThyCa: Thyroid Cancer Survivors’ Association Inc.
P.O. Box 1545
New York, NY 10159-1545
Phone: 877-588-7904
Fax: 630-604-6078
ThyCa is a nonprofit organization developing programs to link survivors and health-care professionals around the world. Their Web site maintains current information about thyroid cancer and support services available to people at any stage of testing, treatment or lifelong monitoring for thyroid cancer, as well as their caregivers. It receives ongoing input and review from numerous thyroid cancer specialists. The site also serves as a resource for anyone interested in thyroid cancer survivors' issues, and includes news for survivors about online chats, conferences, mailing lists and local support groups.
www.thyca.org

EndocrineWeb
EndocrineWeb is a comprehensive Web site for thyroid, parathyroid and other endocrine disorders intended for the education of patients and their families. All pages were written by physicians who treat these diseases.
www.endocrineweb.com

American Thyroid Association
6066 Leesburg Pike, Suite 550
Falls Church, VA 22041
Phone: 703-998-8890
Fax: 703-998-8893
The American Thyroid Association (ATA) is the leading organization focused on thyroid biology and the prevention and treatment of thyroid disorders through excellence and innovation in research, clinical care, education and public health. The ATA Web site features a variety of FAQs and brochures for patients.
www.thyroid.org/patients/index.html

American Cancer Society
Phone: 800-ACS-2345
For TYY: 866-228-4327
The American Cancer Society has many national and local programs, as well as a 24-hour support line, to help cancer survivors with problems such as travel, lodging and emotional issues.
www.cancer.org

National Comprehensive Cancer Network
Phone: 888-909- NCCN (6226)
The National Comprehensive Cancer Network, an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.
www.nccn.org

National Cancer Institute
Phone: 800-4-CANCER
The National Cancer Institute, established under the National Cancer Act of 1937, is the federal government's principal agency for cancer research and training.
www.cancer.gov

U.S. Dept. of Health and Human Services
National Institutes of Health
Phone: 301-496-4000
For TYY: 301-402-9612
The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health and Human Services.
www.nih.gov
 

Thyroid Cancer Team

Thyroid Cancer Team

Support This Program

Support this program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

For more information on supporting this specific program, please contact us below.

Kimberly Wah
Director
Phone: 213-241-7275
Email: kwah@coh.org

 
 
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