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What is Thyroid Cancer?
Thyroid cancer forms when normal thyroid cells undergo genetic changes that cause them to grow in an abnormal way. The most common types of thyroid cancer (papillary and follicular) are typically less aggressive than other cancers.
There are multiple types of thyroid cancer:
- papillary thyroid cancer
- follicular thyroid cancer
- medullary thyroid cancer
- poorly differentiated thyroid cancer
- anaplastic thyroid cancer
Types of Thyroid Cancer
Papillary thyroid cancer (PTC) is the most common type of thyroid cancer, making up approximately 80% of all thyroid cancers. Papillary cancer tends to grow slowly and may spread to the lymph nodes in the neck, but still usually has an excellent prognosis. Most patients with papillary thyroid cancer can be successfully treated with a thorough initial operation, and some patients may require additional treatment with radioactive iodine. Most people are cured (over 95%) and have a normal life expectancy.
Follicular thyroid cancer (FTC) is the second most common type of thyroid cancer, making up 10-15% of all thyroid cancers. It may spread to the lymph nodes in the neck, and is also more likely than papillary thyroid cancer to spread through the blood stream to distant areas (such as the lungs). The prognosis for follicular thyroid cancer remains very good – over 90% of patients are cured.
Hurthle cell cancer is a rare type of follicular thyroid cancer that has many pink-staining cells (so-called oncocytes or Hurthle cells). The pathologist will look for signs of cancer cells invading into surrounding blood vessels or breaking outside of the thyroid, which may predict that the cancer will behave more aggressively.
Poorly differentiated and anaplastic (also known as undifferentiated) thyroid cancer means that the cancer cells do not look or behave like normal thyroid cells. Patients usually present with a rapidly growing neck mass. These are very rare types of thyroid cancer, and occur in less than 2% of cases. Unfortunately, they tend to be very aggressive and not responsive to treatment. Management of these cancers involves a multi-disciplinary team with surgeons, endocrinologists, and medical oncologists. At UCLA, these patients may be treated with recently approved targeted therapies, immunotherapy, or clinical trials.
Medullary thyroid cancer (MTC) makes up 5-10% of all thyroid cancer cases. It is often associated with hereditary conditions (MEN-2), and all patients should undergo genetic testing for a RET gene mutation. If a mutation is found, then the patient’s family members may be at risk for medullary thyroid cancer. In addition, new targeted therapies are available for RET-mutated MTC.
Thyroid Cancer Treatment
Thyroid cancer treatment is very successful. About 95% of thyroid cancer patients live more than five years, and most thyroid cancer patients experience a normal life span and full quality of life after appropriate treatment. Even patients with advanced thyroid cancer may often do well with modern targeted therapies. The key components of thyroid cancer treatment for most types of thyroid cancer are surgery, thyroid stimulating hormone suppression, and ongoing surveillance of tumor markers with dynamic risk stratification. Patients with a high risk of disease recurrence may also be offered radiation therapy with radioactive iodine. Newer targeted therapies and immunotherapy may be used for patients with advanced and metastatic disease outside of the neck.
Key Components of Differentiated* Thyroid Cancer Management
- Thyroid stimulating hormone suppression
- Radioactive iodine ablation (in some patients)
- Dynamic Risk Stratification informed by ongoing surveillance with tumor markers and imaging
* Differentiated thyroid cancer includes Papillary, Follicular, and Hurthle cell thyroid cancer. Treatment for poorly differentiated, anaplastic, and medullary thyroid cancers are distinct and discussed separately.
Surgery is the cornerstone of treatment for most types of thyroid cancer. If the physician suspects that the cancer has spread to lymph nodes in the neck, these will also be removed during surgery. A complete surgery is sufficient treatment for the majority of patients with thyroid cancer.
Choosing the Right Surgery
How thyroid surgery is performed
Thyroid surgery is done through a 1-2 inch incision that is placed in one of the skin creases of the neck, just above the collarbones. We remove one half of the thyroid at a time, so the incision for a thyroid lobectomy and total thyroidectomy are the same size. The size of the incision is kept small as possible for the best cosmetic result.
The crucial parts of the surgery are 1) exposing the thyroid gland, 2) identifying and protecting the parathyroid glands, 3) identifying and protecting the nerve to the vocal cord, 4) removal of the thyroid gland. In most cases, surgery is approximately 1.5 hours for thyroid lobectomy, and 2 hours for a total thyroidectomy. Patients are completely asleep for these procedures.
Thyroid Surgery Step by Step
When to Stop Eating Before Surgery
You are allowed to eat solid food and drink until 8 hours before you are scheduled to arrive for surgery. After that, you can still drink water and clear liquids (anything you can see through) up until 2 hours before you are scheduled to arrive. We encourage our patients to stay hydrated prior to surgery.
For details guidelines on eating and drinking before surgery.
When to arrive for surgery
The nursing staff in charge of the perioperative area will contact you the day prior to your operation with specific instructions on when to arrive. In general, you are asked to arrive a few hours prior to the scheduled time for the operation. This allows adequate time for you to meet the nurses that will take care of you during the operation, the anesthesia team, and the surgery team.
Once you are checked in, you will be brought to the preoperative area. You will have a private space to change your clothes. The operating room nurses, anesthesiologists, and surgery team will come greet you, prepare you for surgery, and answer any last-minute questions. When the operating room is ready, the anesthesiologists may give you some medication to relax. Most people say they do not remember anything past this point when they wake up in recovery.
In the operating room, the anesthesiologists will give you medication to fall asleep. Once you are completely asleep, they will insert a breathing tube or a laryngeal mask.
Patient Positioning and Preparation
We make sure all of your pressure points are padded and support your head. We will tuck your arms by your sides and cover you with a blanket and air warmer. Finally, we do place a soft gel roll behind the shoulders to lift and extend the neck.
Our surgeons always perform neck ultrasound in the operating room. This helps us map the anatomy of the neck prior to operation.
We carefully select the ideal location to make an incision. Our goal is to keep incisions as small as possible.
Exposure of the thyroid
Below the skin lie the muscles of the neck, commonly referred to as strap muscles. We pull these muscles aside to reveal the thyroid gland. In some cases, these muscles are split and reattached.
The area around the upper portion of the thyroid contains 3 important structures: the upper parathyroid gland, a branch of the superior laryngeal nerve that controls pitch, and blood vessels that supply the thyroid. The first two must be carefully preserved while the blood vessels are divided.
The area around the lower portion of the thyroid contains the parathyroid gland as well as the recurrent laryngeal nerve. The parathyroid gland is carefully swept off the thyroid. Normal parathyroid glands are roughly the size of a grain of rice and very delicate. If we believe the blood supply to the parathyroid may be inadequate after freeing it from the thyroid gland, we transplant the parathyroid gland into the sternocleidomastoid muscle in the neck.
Identification and Preservation of the Recurrent Laryngeal Nerve
The most crucial portion of thyroid surgery is the identification and careful dissection of the recurrent laryngeal nerve. This nerve controls the motion of the vocal cord. In some cases, we use a nerve monitoring device.
Before separating the thyroid gland from the trachea, we confirm that we can follow the entire course of the nerve into the larynx.
Excision and Closure
Finally, with the nerves and parathyroid glands protected, we free the thyroid gland from its attachments to the trachea.
The muscles and skin are carefully brought back together. All sutures are dissolvable and placed underneath the skin.
We apply from special skin glue and medical tape known as steristrips.
For most scar photos, please see our scar gallery.
Recovery from thyroid surgery
After surgery patients are observed for a 6-hour period. This is done as a precaution so we can detect and treat any delayed bleeding or swelling. After this period, it is safe for patients to go home if they do not live too far away from the hospital and have family or friends that can stay with them the first night. Otherwise, patients can stay overnight and return home the following morning.
During recovery, pain is usually mild. Most patients only need Tylenol or Advil for pain, and only ~5% need opioid pain medication for additional pain relief. There is no special diet required after surgery.
There is no need to rest the voice after surgery. We encourage patients to resume normal activities, except to avoid heavy lifting for a few weeks. Patients commonly engage in regular exercise about 5-7 days after surgery and can swim after about 2 weeks. Patients should expect to feel more tired than usual after surgery, and we recommend anticipating taking a week off of work to recover.
|Thyroid Lobectomy||Total Thyroidectomy|
|Benefits||No risk to the opposite vocal cord nerve||Required to receive radioactive iodine|
|No risk of insufficient parathyroid hormone||Allows monitoring using a blood test (thyroglobulin)|
|Risks||25% chance of needing thyroid hormone supplementation||Will need lifelong replacement of thyroid hormone (100%)|
|2.5% risk of temporary hoarseness||5% risk of temporary hoarseness|
|<1% hematoma, infection||<1% hematoma, infection|
|May need 2nd surgery to remove other half of thyroid||3% risk of insufficient parathyroid hormone|
- Incision is made in a skin crease in the middle of the neck, in most cases 2 inches or less
- We expose the thyroid gland by separating overlying muscles
- Parathyroid glands are separated and protected
- Nerve to the vocal cord is identified and protected
- Thyroid is removed
A new technique called Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) has been developed. With this surgery, the thyroid gland is removed without leaving any visible scars in the neck. Small incisions are made inside the mouth, and the thyroid gland is removed using a video camera and laparoscopic instruments. In some cases, an additional well-hidden ½ inch incision is made just under the chin.
Good candidates for Scarless Thyroidectomy include patients with smaller thyroid nodules or cancers. This technique is not appropriate for patients with very large or invasive thyroid cancers.
Thyroid stimulating hormone suppression
Following surgery, patients may be treated with thyroid hormone to provide physiologic hormone replacement and to sufficiently suppress pituitary gland secretion of thyroid stimulating hormone (TSH), which is a growth-promoting factor for many types of thyroid cancer. All patients treated with total thyroidectomy (complete thyroid removal) require thyroid hormone therapy with levothyroxine; approximately 25% of patients treated with lobectomy (partial thyroid removal) require thyroid hormone therapy. Thyroid hormone replacement is usually provided as a daily oral pill called levothyroxine. Your endocrinologist will monitor blood tests, including a TSH level, to determine the optimal dose for managing your thyroid hormone balance and the recurrence risk of your thyroid cancer (see Dynamic Risk Stratification below). In general, patients with more aggressive disease and higher risk of recurrence are initially managed with levothyroxine to suppress the TSH level (<0.1mIU/L), while patients with lower risk of recurrence and/or other health factors that would increase their risk from side effects are managed with a TSH in the lower half of the normal reference range (2-0.5mIU/L). Levothyroxine thyroid hormone therapy and TSH suppression in thyroid cancer patients are individualized and change over time based upon the risk of disease recurrence.
Will I feel different taking thyroid hormone pills?
Fortunately, a well-tolerated and safe form of thyroid hormone therapy is available, called levothyroxine (also known as Levoxyl or Synthroid; Tirosint is a gluten free formulation). This is the recommended medication to treat hypothyroidism following thyroid surgery and to suppress TSH in patients with a history of thyroid cancer. Most patients achieve a normal thyroid balance and feel well within 6-8 weeks of starting therapy or sooner when followed by an endocrinologist. Your doctor will monitor thyroid function tests over time to ensure that your dose is optimal for both your thyroid balance and controlling your thyroid cancer. More information about thyroid hormone tests and thyroid hormone medication can be found here: Normal Thyroid Hormone Levels.
Radioactive iodine (RAI) ablation therapy
Patients with a high risk of disease recurrence may also be offered radiation therapy with radioactive iodine. At UCLA, we estimate that about 1 in 4 patients may need radioactive iodine as part of their thyroid cancer treatment. Radioactive iodine takes advantage of the preferential uptake of iodine by thyroid tissue to allow radiation treatment of residual and microscopic thyroid cancer with minimal side effects on other organs. Therapy is done in collaboration with a nuclear medicine physician and is given by an oral pill that the patient swallows. Patients remain isolated at home or in the hospital for several days after taking the radioactive iodine, followed by an imaging scan 5 days after therapy. To improve the efficacy of RAI therapy, patients are asked to follow a low iodine diet for 10-14 days prior to therapy and may be instructed to withdrawal from thyroid hormone medication or receive an injection of Thyrogen to sensitize any remaining thyroid tissue to RAI. Additional information about radioactive iodine therapy and a low iodine diet can be found on the American Thyroid Association patient education site. Radioactive iodine therapy is generally safe and can be highly effective for some kinds of thyroid cancer. Common side effects include dry mouth and eyes after therapy. Recent data suggests that even lower doses of radioactive iodine may be effective in reducing the risk of thyroid cancer recurrence, further reducing the risks of side effects from radioactive iodine ablation therapy.
Dynamic Risk Stratification informed by ongoing surveillance with tumor markers and imaging
After initial therapy for thyroid cancer, patients continue regular disease surveillance under the care of an endocrinologist. Ongoing disease monitoring includes measurement of tumor marker thyroglobulin in the blood and thyroid/neck ultrasound imaging at regular intervals.
Thyroglobulin levels are usually evaluated 4-6 weeks after initial therapy, at 6 months, and then every 6-12 months based upon clinical response. Thyroid ultrasound surveillance typically occurs at 12 months after therapy and annually thereafter.
Your endocrinologist will follow your tumor marker thyroglobulin over time. Persistently elevated or a rising thyroglobulin tumor marker may prompt your physician to perform other evaluations to locate persistent or recurrent thyroid cancer, such as a physical exam, neck ultrasound or computed tomography (CT) imaging, or iodine uptake whole body scans.
At the UCLA Endocrine Center, we utilize a strategy of dynamic risk stratification during thyroid cancer follow-up. Dynamic risk stratification incorporates measurement of tumor markers and imaging surveillance information to continually re-evaluate in each patient the risk of clinically significant thyroid cancer recurrence or progression. This risk stratification then guides recommendations for further diagnostic evaluation, TSH suppression and additional therapy in a way that optimally balances the benefits of additional treatment with risks and side effects. For example, thyroid hormone suppression of TSH is relaxed in patients with excellent response to treatment and low risk of recurrence to minimize the risk of heart arrhythmias and osteoporosis that can result from long term TSH suppression therapy.
Active Surveillance of Low-Risk Thyroid Cancer
While surgery is the initial management for most thyroid cancers, in an appropriately selected group of patients with low risk disease, active surveillance may be an alternative strategy to immediate surgery. Recent data suggest that management with active surveillance may allow patients with low risk disease to avoid or delay surgery for thyroid cancer without significant increases in disease spread or overall survival outcomes.
Active Surveillance of Thyroid Cancer
UCLA endocrine surgeon James Wu, MD, presented a live-streaming webinar to discuss active surveillance of low-risk tumors, a recommended treatment approach for many incidentally discovered papillary thyroid cancers.
Treatment of Recurrent Thyroid Cancer
Every year, approximately 50,000 new diagnoses of thyroid cancer are made. Since very few patients die from their thyroid cancer, recurrences are frequently encountered. Fortunately, most recurrences in the neck can still salvaged with surgical resection.
Recurrences can be detected through blood tests, neck ultrasound, and physical examination. Consultation with an endocrinologist and endocrine surgeon should be sought to determine the site and extent of recurrent disease.
Treatment options for recurrent thyroid cancer include additional surgery, use of radioactive iodine, targeted therapies, and in some cases, observation with close monitoring. The choice of further treatment often hinges on the location and extent of the recurrent disease and response to prior therapy. Diseased lymph nodes in the neck are usually removed surgically. Disease outside the neck is often treated with radioactive iodine, external beam radiation, or new systemic targeted therapies.
Management of Advanced Thyroid Cancer and Anaplastic Thyroid Cancer
For advanced thyroid cancer that persists or recurs after surgery, radioactive iodine ablation, and thyroid hormone TSH suppression, additional therapies may be required. Furthermore, patients with poorly differentiated or anaplastic thyroid cancer often require systemic targeted therapy or immunotherapy given in collaboration with medical oncologists.
Improved understanding of the pathogenesis of these cancers is leading to the development of new agents aimed at specific oncogenic mechanisms, called targeted therapies. Targeted therapies approved for the treatment of advanced thyroid cancer include tyrosine kinase inhibitors (lenvatinib, sorafenib, and cabozantinib), multi-kinase inhibitor vandetinib, and RET fusion inhibitor selpercatinib. Additionally, clinical trials are ongoing to evaluate BRAF inhibitors and immunotherapy with checkpoint inhibitors in patients with advanced thyroid cancers.
In rare situations, thyroid cancer spreads to other sites in the body, including the lungs, bones, and brain. Disease in these sites may not be amenable to surgical resection and therefore adjuvant therapies are often used. Lung metastases are the most common site of distant thyroid cancer spread. When lung metastases are large or cause symptoms like shortness of breath, treatment with radioactive iodine, external beam radiation, or targeted therapies may be recommended. Bone thyroid cancer metastases can also occur rarely and may cause bone pain or increased risk of fracture. Treatments available for thyroid cancer bone metastases include external beam radiation, systemic targeted therapy, and bone strengthening medications.
Special Populations with Thyroid Cancer
As a referral center for difficult cases, we also have experience in treating patients with special circumstances.
We are also part of specialized teams that care for patients and their families with:
- Multiple Endocrine Neoplasia (MEN-1, MEN-2A, MEN-2B, MEN4)
- Familial pheochromocytoma
Contact us today for an appointment.