Thyroid Neoplasms: 4 (Advances in Molecular and Cellular Endocrinology)
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The tumor emboli do angioinvasion of lungs; end of long bones, skull, and vertebrae are affected. Pulsating metastases occur because of their increased vascularity. Thyroidectomy and dissection of central neck compartment is initial step in treatment of thyroid cancer in the majority of cases.
Radioactive iodine is used in people with papillary or follicular thyroid cancer for ablation of residual thyroid tissue after surgery and for the treatment of thyroid cancer. External irradiation may be used when the cancer is unresectable, when it recurs after resection, or to relieve pain from bone metastasis. Sorafenib and lenvatinib are approved for advanced metastatic thyroid cancer. The prognosis of thyroid cancer is related to the type of cancer and the stage at the time of diagnosis.
For the most common form of thyroid cancer, papillary, the overall prognosis is excellent. Indeed, the increased incidence of papillary thyroid carcinoma in recent years is likely related to increased and earlier diagnosis. One can look at the trend to earlier diagnosis in two ways. The first is that many of these cancers are small and not likely to develop into aggressive malignancies. A second perspective is that earlier diagnosis removes these cancers at a time when they are not likely to have spread beyond the thyroid gland, thereby improving the long-term outcome for the patient.
No consensus exists at present on whether this trend toward earlier diagnosis is beneficial or unnecessary. The argument against early diagnosis and treatment is based on the logic that many small thyroid cancers mostly papillary will not grow or metastasize.
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This view holds the overwhelming majority of thyroid cancers are overdiagnosed that is, will never cause any symptoms, illness, or death for the patient, even if nothing is ever done about the cancer. Including these overdiagnosed cases skews the statistics by lumping clinically significant cases in with apparently harmless cancers. Benign noncancerous nodules frequently co-exist with thyroid cancer; sometimes, a benign nodule is discovered, but surgery uncovers an incidental small thyroid cancer. Increasingly, small thyroid nodules are discovered as incidental findings on imaging CT scan, MRI, ultrasound performed for another purpose; very few of these people with accidentally discovered, symptom-free thyroid cancers will ever have any symptoms, and treatment in such patients has the potential to cause harm to them, not to help them.
The table below highlights some of the challenges with decision making and prognostication in thyroid cancer.
Thyroid Cancer: Practice Essentials, Overview, Clinical Presentation
While general agreement exists that stage I or II papillary, follicular, or medullary cancer have good prognoses, when evaluating a small thyroid cancer to determine which ones will grow and metastasize and which will not is not possible. As a result, once a diagnosis of thyroid cancer has been established most commonly by a fine needle aspiration , a total thyroidectomy likely will be performed.
This drive to earlier diagnosis has also manifested itself on the European continent by the use of serum calcitonin measurements in patients with goiter to identify patients with early abnormalities of the parafollicular or calcitonin-producing cells within the thyroid gland. In Europe where the threshold for thyroid surgery is lower than in the United States, an elaborate strategy that incorporates serum calcitonin measurements and stimulatory tests for calcitonin has been incorporated into the decision to perform a thyroidectomy; thyroid experts in the United States, looking at the same data, have for the most part not incorporated calcitonin testing as a routine part of their evaluations, thereby eliminating a large number of thyroidectomies and the consequent morbidity.
The European thyroid community has focused on prevention of metastasis from small medullary thyroid carcinomas; the North American thyroid community has focused more on prevention of complications associated with thyroidectomy see American Thyroid Association guidelines below. As demonstrated in the table below, individuals with stage III and IV disease have a significant risk of dying from thyroid cancer.
While many present with widely metastatic disease, an equal number evolve over years and decades from stage I or II disease. Physicians who manage thyroid cancer of any stage recognize that a small percentage of patients with low-risk thyroid cancer will progress to metastatic disease. Improvements have been made in thyroid cancer treatment during recent years. The identification of some of the molecular or DNA abnormalities has led to the development of therapies that target these molecular defects.
The first of these agents to negotiate the approval process is vandetanib , a tyrosine kinase inhibitor that targets the RET proto-oncogene , two subtypes of the vascular endothelial growth factor receptor , and the epidermal growth factor receptor. For differentiated thyroid carcinoma, strategies are evolving to use selected types of targeted therapy to increase radioactive iodine uptake in papillary thyroid carcinomas that have lost the ability to concentrate iodide.
This strategy would make possible the use of radioactive iodine therapy to treat "resistant" thyroid cancers. Other targeted therapies are being evaluated, making life extension possible over the next 5—10 years for those with stage III and IV thyroid cancer. Prognosis is better in younger people than older ones.
Prognosis depends mainly on the type of cancer and cancer stage. Thyroid cancer, in , resulted in 36, deaths globally up from 24, in Around 2, people were diagnosed with thyroid cancer in the UK in , and around people died from the disease in From Wikipedia, the free encyclopedia. Thyroid cancer Micrograph of a papillary thyroid carcinoma demonstrating diagnostic features nuclear clearing and overlapping nuclei. Further information: Thyroid nodule. This section needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed.
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Archived from the original on 20 May World J Surg. Iranian Journal of Pathology. Endocrine-Related Cancer. Journal of Nuclear Medicine. A concise textbook of surgery 5th. Calcutta: Dr S. Guidelines for the management of thyroid cancer. Whatever path is chosen, Worden noted, the treating clinician must have meaningful discussions with the patient regarding when to start treatment.
We do have drugs that are helpful; however, just because we have these drugs does not mean we should be using them. In patients with thyroid cancer refractory to radioactive iodine, levothyroxine therapy is administered to maintain a low serum thyroid-stimulating hormone level, unless contraindications are present, and focal treatment on metastases is performed whenever needed, Amandine Berdelou, MD, a researcher with the Gustave Roussy Oncology Institute in Villejuif, France, and colleagues wrote in a review in Endocrine Related Cancer.
Surveillance includes a fluorodeoxyglucose-positron emission tomography or a CT scan at intervals ranging from every 3 to 12 months, depending on tumor burden, location disease progression and time to doubling of serum thyroglobulin. To date, three medications have been evaluated in randomized phase 3 trials vs. Participants had radioiodine refractory locally advanced or metastatic DTC that had progressed within the past 14 months.
In the SELECT trial, researchers randomly assigned patients with radioactive iodine refractory locally advanced or metastatic DTC that had progressed within the past 13 months to lenvatinib 24 mg per day or placebo. More recently, in data from the phase 3 ZETA trial presented in October at the European Society for Medical Oncology Congress, vandetanib induced tumor shrinkage that persisted throughout multiple treatment lines for patients with advanced unresectable medullary thyroid cancer. With most of the patients that I do treat, we can find a dose that is satisfactory for the patient and provides efficacy.
In determining the best treatment to use, routine mutation screening should be performed, Busaidy said, as the presence of a mutation can lead to the use of a specific inhibitor. The rise of immunotherapy may further alter the fate of patients with thyroid carcinoma, whether differentiated, medullary or anaplastic, Faugeras and colleagues wrote. Programmed death-ligand 1 PD-L1 expression on tumor cells is emerging as a potential predictive biomarker in anti-PD-L1-directed cancer immunotherapy. In a recent retrospective study on the overexpression of PD-L1 in papillary thyroid cancers published in Oncotarget , researchers showed that the protein is correlated with an increased risk for relapse and is a marker of poor prognosis.
However, researchers agree that immunotherapy therapy is in its infancy with respect to thyroid cancer. As with other thyroid cancer treatments, Busaidy said, the problem is determining who is an ideal candidate for immunotherapy. In clinical trials with tyrosine kinase inhibitor therapies, participants reported multiple adverse events that ultimately led to dose reduction or withdrawal for some patients, ranging from hand-foot-skin reactions to a marked increase in hypertension.
In the DECISION trial, sorafenib exhibited the expected safety profile, but researchers observed a higher incidence of adverse events than seen in patients with other cancer types.
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Overall, Busaidy said, available thyroid cancer therapies are well-tolerated, and a clinician should not be afraid to prescribe them. In , the FDA approved several new therapies for the treatment of thyroid cancer. The approval marks the second so-called tissue-agnostic FDA approval for the treatment of cancer and offers patients with refractory thyroid cancer a new option, Misiukiewicz said. You need to stratify and categorize with each patient, case by case. Once you know the tumor personality, you can develop a good strategy.
Disclosures: Busaidy reports she has received consultant fees from Eisai and Loxo Oncology and research funding from Novartis. Lee reports no relevant financial disclosures. Misiukiewicz reports he has received speaking fees from Eisai. Nucera reports he has served on an advisory board for Loxo Oncology for therapeutics development not reported in this article.
Worden reports he has received consultant fees from Bayer and research funding from Eisai. Click here to read the , "Should lenvatinib or sorafenib be the first agent used in slowly progressing radioiodine-refractory thyroid carcinoma? Tell us what you think about Healio. Login Register My Saved. Cover Story. Endocrine Today, February Please provide your email address to receive an email when new articles are posted on this topic.