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Anaplastic Thyroid Cancer Treatment

Anaplastic thyroid cancer surgery is introduced here. Let's be very clear, very few surgeons should ever do surgery for anaplastic thyroid cancer. It is the most rare thyroid cancer, the most lethal thyroid cancer, and the most complicated thyroid cancer to perform. The correct operation depends upon the anaplastic thyroid cancer extent of invasion and is often only even considered appropriate when there is no evidence that there is any distant spread of the disease. The only opportunity for cure of anaplastic thyroid cancer is one complete thyroid surgery that effectively removes all of the cancer within the neck! What is most important, is that all of the anaplastic thyroid cancer is removed from the neck in this initial operation! Incomplete surgery is not correctable! The extent of comprehensive surgery depends upon what the anaplastic thyroid cancer has grown into and where it has spread in the neck. Although the cells may look different under the microscope from one anaplastic thyroid cancer compared to another anaplastic thyroid cancer, what the cells look like under the microscope has no bearing upon the type or extent of the surgery required. Unlike other thyroid cancers, surgery for anaplastic thyroid cancer is urgent if it is feasible. Only the most expert of thyroid cancer surgeons can determine whether an anaplastic thyroid cancer is meaningfully able to be operated upon. However, ultimately, this decision rests solely upon the patient with the anaplastic thyroid cancer. In rare circumstances, an anaplastic thyroid cancer may be discovered following the complete removal of a thyroid tumor once the pathology (what it looked like under a microscope) has been reviewed. In such circumstances, it is not urgent to proceed with completion surgery but prompt evaluation for distant spread of the anaplastic thyroid cancer and additional chemotherapy and radiation therapy to prevent recurrence of the cancer within the neck. Other targeted treatments are now available for anaplastic thyroid cancer patients which were previously never available. Additionally, new treatments including immmunologic therapy and clinical research continue to become available for patients with anaplastic thyroid cancer. The Clayman Thyroid Center works seemlessly with experts around the world to offer comprehensive interdisciplinary managment for patients with anaplastic thyroid cancer. Again, but if thyroid surgery is feasible, it is both urgent but also most importantly, must be expertly performed. Last updated March 21, 2021.

Anaplastic thyroid cancer treatment depends upon the stage of the cancer (How big it is, where the cancer is located within the body, and what it looks like under the microscope), the patient’s overall health, and the patient’s desires. This section discusses the typical treatment options for your anaplastic thyroid cancer. Treatment decision making is based upon three important factors:

What is the optimal treatment for your particular anaplastic thyroid cancer
What are the patient’s desires
What are the capabilities and outcomes of the thyroid cancer team

Anaplastic Thyroid Cancer Surgery: Extended/Comprehensive (Appropriate) Surgery Is The Only Way.

Anaplastic thyroid cancer surgery is not simple or ever minimally invasive. In every instance which I have operated on an anaplastic thyroid cancer, one of the nerves to the voice box has already been invaded by the anaplastic thyroid cancer and paralyzed half of the voice box. You should not be concerned over this event. You can continue to have a voice although its quality may be hoarse. Often times, the quality of the voice can be improved in patients with anaplastic thyroid cancer following the completion of their treatment.

Anaplastic thyroid cancer surgery has no bleeding associated with it. Literally, a teaspoon or two of blood may be lost in these surgeries. But don’t get me wrong. It must be an extensive surgery. Anaplastic thyroid cancer surgery for the thyroid requires removing all of the thyroid that is involved with the cancer! But unlike other thyroid cancers, although total removal of the thyroid gland (total thyroidectomy) is often appropriate, it is not always necessary. If the other side of the thyroid gland is not involved with anaplastic thyroid cancer or any other type of nodule or mass, it need not routinely be removed. In that way, the uninvolved nerves of the voice box and glands that control calcium (parathyroid glands) are at no risk whatsoever. The anaplastic thyroid cancer almost uniformly will grow outside of the thin capsule of the thyroid gland and extend into muscles of the neck and esophagus. It often grows into the nerve of the voice box (the recurrent laryngeal nerve) and superficially or deeply may grow into the trachea (breathing tube). Because anaplastic thyroid cancer surgery will be almost always so extensive, sometimes less on the side of the uninvolved thyroid gland can be a sound approach. Again, these types of decisions must be made by the most experienced thyroid cancer surgeons.

For anaplastic thyroid cancer of the thyroid to be cured, surgery is the most critical first treatment. In fact, if anaplastic thyroid cancer surgery is not feasible, there is currently no known cure for this disease. It cannot be emphasized enough, that only the most experienced thyroid cancer surgeon is obtained immediately. Anaplastic thyroid cancer surgery should only be done by the most expert of thyroid cancer surgeons. Lesions that are highly suspicious for a risk of anaplastic thyroid cancer (even if under the microscope it may be called “poorly differentiated thyroid cancer”) should be removed with the same surgical approach as for an anaplastic thyroid cancer! The surgery for anaplastic thyroid cancer is often a total or near total thyroidectomy. This type of thyroid surgery should only be performed by highly experienced thyroid cancer surgeons.

Editors note: Over the past twenty-seven years, I have cared for many anaplastic thyroid cancer patients. The only patients who have been able to survive their anaplastic thyroid cancer are those patients which came promptly with their diagnosis and had no surgery before they saw me. Anaplastic thyroid cancer patients, who I have seen over this same time period that underwent incomplete removal of their cancer are plagued with inability to control the cancer within their neck, difficulty breathing, bleeding and too many scary problems to even discuss. Many of these patients had the wrong or poorly planned surgery. Think clearly and move promptly. Anaplastic thyroid cancer can grow at such an incredible rate that literally a week can make a major difference.

Most importantly, if the anaplastic thyroid cancer has not yet spread to distant sites, by choosing the right expert thyroid cancer surgeon and surgery, you can potentially be cured. The wrong choice in surgeon is not correctable!

Thyroid surgery was one of the first ever described surgeries in medicine, but early on it wasn’t very pretty or safe. Over the past 100 years, thyroid surgery has evolved into its current state of the art by some of the most recognized names in surgical history. Today, in skilled hands, anaplastic thyroid cancer surgery may be considered an art form in its own right.

Anaplastic thyroid cancer surgery must be considered in several different lights when you think about the neck:

Surgery of the thyroid gland itself
Surgery for the surrounding soft tissues around the thyroid gland
Surgery for the lateral and central compartments of the neck

Anaplastic thyroid cancer was once thought to be the worst type of differentiated papillary thyroid cancer. Clearly, some anaplastic thyroid cancers appear to develop within long standing existing papillary thyroid cancers. However, other anaplastic thyroid cancers appear to develop in a different manner within the thyroid gland. Whether one of these may be more favorable than the other remains to be determined. However, whichever pathway the anaplastic thyroid cancer appears to develop from probably makes little to no difference regarding the aggressive nature of the cancer. One thing for certain, it certainly makes no impact upon current treatment approaches especially the extent of surgery.

Anaplastic thyroid cancer has a predictable ability to grow into adjacent structures in the neck as well as spread into the lymph nodes of the neck. The surgery for anaplastic thyroid cancer must be a true “three dimensional” removal of the cancer. What I mean by that is that the surgery must get “all around the anaplastic thyroid cancer”. Therefore, for an anaplastic thyroid cancer, the thin muscles that lay on top of the thyroid gland need to be removed with the cancer. These muscles have very little functional importance and most patients note no functional outcome with their removal. It does make the front of the neck slightly concave and the trachea is more noticeably under the skin when you are done healing.

In removing an anaplastic thyroid cancer, the other areas to “get around” are a little more tricky. One big difference between these cancers is that anaplastic thyroid cancer has a significant ability to spread to local lymph nodes, especially underneath the thyroid gland. These lymph nodes are involved in almost all anaplastic thyroid cancers. Even if they are not involved by the spread of anaplastic thyroid cancer, they still need to be removed since the anaplastic thyroid cancer can growth directly into them. Now some things are not reasonable to be removed with an anaplastic thyroid cancer surgery, when you attempt to “get around the cancer”. The expert thyroid cancer surgeon needs to make important surgical planning and approaches to dealing with the critical blood vessel like the carotid artery, and the trachea, voice box, and esophagus. These structures need to be preserved in anaplastic thyroid cancer surgery but still providing a high likelihood of removing all of the anaplastic thyroid cancer or at least just leaving microscopic remaining cancer cells. If this sounds complicated, it is, but this is the importance of having your anaplastic thyroid cancer treated by an expert thyroid cancer surgeon.

If anaplastic thyroid cancer is incompletely removed following the first surgery, this is called persistent anaplastic thyroid cancer. There is no more meaningful surgery that can then be performed. You only have one opportunity to operate on anaplastic thyroid cancer, make sure it is with a truly expert thyroid cancer surgeon!

If anaplastic thyroid cancer comes back after the first surgery, this is called recurrent anaplastic thyroid cancer. In these instances, there is no ability to perform another surgery which will be meaningful for the patient. There may be the ability to operate but it will not offer the anaplastic thyroid cancer patient any opportunity for cure.

The basic concept is very simple, remove all of the anaplastic thyroid cancer during the first and only surgery!

Anaplastic thyroid cancer can be approached by three basics types of thyroid gland surgery: What are they and what is right for me?

One is removal of about half of the thyroid gland. This is called a thyroid lobectomy.
The other is removal of all of the thyroid gland and is called total thyroidectomy.
The third type of thyroidectomy is called a subtotal thyroidectomy where almost all of the thyroid gland is removed

(Editors note: Almost all anaplastic thyroid cancers are treated primarily with removal of the entire thyroid gland (total thyroidectomy) or subtotal thyroidectomy.

Editors note: In very rare circumstances, an anaplastic thyroid cancer will be discovered on final pathologic review of a surgical specimen without knowledge that it was present before the surgical procedure. The first thing to do in such a circumstance is to make sure that an expert thyroid cancer pathologist has reviewed the microscopic examination of the specimens. The second thing to do is to not take this diagnosis lightly. It may be possible that the surgery just coincided with establishment of this very aggressive cancer. These “favorable” anaplastic thyroid cancers may be curable but certainly require interdisciplinary thyroid cancer team evaluation and treatment planning.

One issue that is critically important in the understanding of the treatment of anaplastic thyroid cancer is that the blood marker of thyroid, thyroglobulin, may rarely be detectable with this cancer, but thyroglobulin (or any other protein for that matter), are generally not used in the follow-up of anaplastic thyroid cancer patients.

Anaplastic thyroid cancers are generally quite large and almost never found early in their disease course. In reviewing, anaplastic thyroid cancer staging, you will see that there is no such thing as “early” anaplastic thyroid cancer disease. Although, in concept, an anaplastic thyroid cancer may be so small and the remainder of the thyroid gland may be so normal that a thyroid lobectomy would be a potentially appropriate surgery, however I have never seen such an instance in my entire professional career and I have also not heard of a case as well.

Thyroid Lobectomy

In this surgery, about half of the thyroid gland is removed. A small incision in the lower neck is required which is about two inches in length unless the thyroid mass requires a longer length to allow it to be “delivered”. Even if the plan in surgery for an anaplastic thyroid cancer is removal of only half of the thyroid gland, the surround central compartment lymph nodes should be removed with the same side of the thyroid gland. Additionally, at least the muscle which lays immediately on top of the anaplastic thyroid cancer should be removed even in the most favorable of anaplastic thyroid cancer cases. For an anaplastic thyroid cancer, undergoing a thyroid lobectomy, I would prefer to have a good complete excision of this most severe cancer more than saving either of the adjacent parathyroid glands. If the parathyroid glands on the side of the anaplastic thyroid cancer are quite distant from the cancer, they can be spared an left in place but should not be transplanted since anaplastic thyroid cancers can grow essentially anyplace including transplant sites and skin. In anaplastic thyroid cancer surgery, it is better to be cautious and not retain parathyroid tissue if there is even remote concern that anaplastic thyroid cancer cells may be present in the immediate vicinity of retained or transplantable parathyroid tissue. Unless the anaplastic thyroid cancer is directly invading either of the critical nerves that provide movement and sensation to the voice box, they should be spared. Although this sounds like straight forward surgery, there is only one opportunity to defeat anaplastic thyroid cancer with surgery!! Anaplastic thyroid cancer patients most important task is to do their homework and choose the right surgeon to do the right surgery.

Editors note: A thyroid lobectomy is not recommended when anaplastic thyroid cancer patients have nodules present in both sides of the thyroid gland or you have a greater than 2 centimeter anaplastic thyroid cancer (almost always anaplastic thyroid cancers are large when they are diagnosed).

May be an effective surgical treatment for small (up to 2 cm or 1 inch) anaplastic thyroid cancers (although I would not recommend it).
The lymph nodes on the side of the thyroid surgery should be removed comprehensively with the cancer on the same side of the cancer
Cosmetically acceptable incision design
Essentially little to no risk of hypoparathyroidism (low blood calcium)
Outpatient surgical procedure
Return to normal aerobic activities and daily functions in 24 hours.
No heavy lifting for three weeks
Remaining thyroid tissue facilitates ease in thyroid hormone regulation.
Only one nerve to the voice box is even at theoretical risk of injury.

Total Thyroidectomy

For anaplastic thyroid cancer, total thyroidectomy is frequently the preferred surgery. In this surgery, the entire thyroid gland is removed. A small incision in the lower neck is required which is about 2 inches in length unless the anaplastic thyroid cancer requires a longer length to allow it to be “delivered”. Most anaplastic thyroid cancers are 4 cm or greater and therefore the respective incision must be long enough to accommodate the largest dimension of the anaplastic thyroid cancer or thyroid itself. In anaplastic thyroid cancer surgery, all of the critical nerves that provide movement (recurrent laryngeal nerves) and sensation to the voice box (superior laryngeal nerves) are spared unless directly invaded or functionally involved with the cancer. The lymph nodes along the side and beneath (and the thin overlying muscles covering) the anaplastic thyroid cancer are also removed with the anaplastic thyroid cancer during this surgery. This anaplastic thyroid cancer surgery insures that the potential direct extension of the anaplastic thyroid cancer has been removed and adequately addressed .

When should you consider removing the entire thyroid gland (total thyroidectomy)?

The anaplastic thyroid cancer is more than 2.0 centimeters or 1 inches

The anaplastic thyroid cancer appears to have extended outside of the surface of the thyroid gland (called its capsule)[almost always the case]

The anaplastic thyroid cancer has spread to the lymph nodes underneath the thyroid gland (called central compartment lymph nodes [also called Level VI or VII lymph nodes] of the neck) or the lateral neck. This is almost uniformly found in anaplastic thyroid cancer patients!/li>

Extended or Complicated Thyroidectomy

Anaplastic thyroid cancer almost always is aggressive locally when it initially presents. Imaging prior to surgery such as ultrasound or CT frequently detects these aggressive anaplastic thyroid cancer’s extension. In some instances, imaging may not adequately predict this invasive component of the anaplastic thyroid cancer. Let me tell you, there is no such thing as a “good” anaplastic thyroid cancer. For anaplastic thyroid cancer, there is no second chance for surgery. The first surgery must be the right surgery and the only surgery!! In anaplastic thyroid cancer, an expert thyroid cancer surgeon that recognizes the typical anaplastic thyroid cancer “more aggressive” intraoperative findings such as growth or extension of the cancer outside of the thyroid gland or invasion of the cancer into adjacent structures such as the nerve to the voice box (recurrent laryngeal nerve), breathing tube (trachea), voice box, or esophagus-must adapt the surgery to adequately address the complete removal of the cancer. Unfortunately, most thyroid surgeons are commonly unprepared to perform the appropriate surgery and another meaningful surgery for anaplastic thyroid cancer is not feasible following an incomplete initial surgery.

Anaplastic thyroid cancer Surgery for Central Compartment Lymph Nodes (the lymph nodes beneath and surrounding the thyroid gland, breathing tube (trachea) and swallowing tube (esophagus)

The removal of the lymph nodes of the central neck should be performed initially when the thyroid gland is removed in the treatment of anaplastic thyroid cancer on the side of the cancer (see total thyroidectomy and central compartment dissection). Central compartment dissection extends from the carotid arteries on both sides of the neck, below to the blood vessels of the upper chest, and above to where the blood vessel of the upper portion of the thyroid gland begins off of the carotid artery (called the superior thyroid artery).

In anaplastic thyroid cancer, the central compartment neck dissection is more commonly seen as a method of three dimensionally “getting around the cancer” more often than just removing the lymph nodes themselves.

In anaplastic thyroid cancer, the central compartment lymph nodes are at risk of containing cancer in at least 90% of patients. That risk increases with the size of the anaplastic thyroid cancer. Even prior to surgery, most central compartment lymph nodes can be well examined with high quality ultrasound to determine if they are cancerous. Enlarged or abnormal lymph nodes seen on ultrasound next to the thyroid gland before surgery should be examined. These abnormal lymph nodes undergo fine needle aspiration (FNA) examination to determine whether anaplastic thyroid cancer is present. Frequently, in anaplastic thyroid cancer, the neck lymph nodes may be more informative when the cells are looked at under a microscope than the cells of the thyroid gland itself.
In anaplastic thyroid cancer surgery, preservation of nerve function which is not involved by the cancer is of the most critical importance. In every patient that I have operated on for anaplastic thyroid cancer, one of their nerve’s to the voice box was already paralyzed before I did their surgery. You must understand that if both nerves to the voice box are paralyzed in any patient, they likely will never be able to breath adequately unless they have a breathing tube in the neck (called a tracheostomy). Only the most expert thyroid cancer surgeon should ever perform anaplastic thyroid cancer surgery. Anaplastic thyroid cancer surgery not performed by a true expert risks tracheostomy, permanent loss of calcium control in the body, and inability to ever control the cancer!!! If you or your loved one has an anaplastic thyroid cancer, only let an expert promptly evaluate you and consider surgery!
In larger anaplastic thyroid cancers which are greater than 2 centimeters (less than an inch!!!), a very extensive removal of the lymph nodes of the central compartment on the side of the cancer should be always done:
- In anaplastic thyroid cancer there is only one chance for surgery cure. The expert anaplastic thyroid cancer surgeon understands exactly what needs to do done at the time of surgery. There is no margin for error. In the rare circumstance that the nerve to the voice box (recurrent laryngeal nerve) has able to be spared, then all of the surrounding tissue which is both lymph nodes and fatty tissue and a thin muscle on top of the thyroid gland must be removed with the thyroid and cancer. If you can possible imagine, the best anaplastic thyroid cancer surgery would be one that I never really see or touch the anaplastic thyroid cancer throughout the surgery. In that way, the expert anaplastic thyroid cancer surgeon has completely gone around the cancer!!!! (see video of what the recurrent laryngeal nerve looks like)
- 2) The risk of anaplastic thyroid cancer going to the lymph nodes in the central neck is over 90%. The removal of these local lymph nodes with anaplastic thyroid cancer also allows surgery to “get around” the cancer.

Anaplastic Thyroid Cancer Surgery For Spread of Cancer to Lymph Nodes Along The Side Of The Neck (anterolateral neck)

Just the presence of enlarged lymph nodes does not mean anaplastic thyroid cancer has spread and does not require additional surgery
A procedure called an anterolateral neck dissection (or modified neck dissection), in untreated patients, should only be performed when:
- ultrasound with fine needle aspiration confirmed anaplastic thyroid cancer spread to lymph nodes in the side of the neck
- the anaplastic thyroid cancer is so large that the expert thyroid cancer surgeon must “get around” the cancer by identifying all the structures to save in the anterolateral neck. This includes the carotid artery, jugular vein, critical nerves to the voice box, critical nerve to the diaphragm (bellows of the lung), nerves to the upper shoulder and arm….just to name a few. Now you understand why you truly need an thyroid cancer surgery expert.
The anaplastic thyroid cancer anterolateral neck dissection is not the same neck dissection as for other cancers that occur in the neck. All thyroid cancers spread to particular areas of the neck called levels. Removing just some of the lymph nodes has been called “cherry picking” and is the wrong surgery! A thyroid cancer expert surgeon trained and experienced to perform modified neck dissections specifically for anaplastic thyroid cancer is needed to potentially cure this dreaded cancer. There is no second chance to cure anaplastic thyroid cancer!!!
The anterolateral neck dissection, in skilled hands, spares all critical nerves, muscles, and blood vessels which are not directly involved with cancer (critical structures may be involved by anaplastic thyroid cancers). In anaplastic thyroid cancer surgery, only directly invaded critical structures need to removed. Only an expert anaplastic thyroid cancer surgeon should make such critical decisions. Anaplastic thyroid cancer neck dissection is an approximately 40 minute surgery that removes lymph nodes and fatty tissue. (see a thyroid cancer modified neck dissection)
In some circumstances, anaplastic thyroid cancers may show extensive growth into the the soft tissues of the neck. In such circumstances, a special surgery that can “get around” the anaplastic thyroid cancer can be safely performed to remove all of the cancer by an expert thyroid cancer surgeon.

Anaplastic Thyroid Cancer Surgery in Sites Other Than The Neck

Anaplastic thyroid cancer surgery is uncommonly proposed as a treatment approach when disease has spread to distant sites. Although surgery is not commonly proposed for distant spread of anaplastic thyroid cancer, consideration for surgery for distant disease is based upon the expert thyroid cancer team evaluation and considers the following issues:

Where is the anaplastic thyroid cancer distant disease located?
What are the risks and benefits of surgery?
Are there other sites of distant spread?
What anaplastic thyroid cancer treatments have already been used?
What were the outcomes of other treatments for the anaplastic thyroid cancer?
How fast is the anaplastic thyroid cancer growing?
What are the patient’s treatment desires?
What are the other treatment options?
What are the anaplastic thyroid cancer genetic mutations found?

Anaplastic Thyroid Cancer Robotic Surgery-Why It Should Never Be Done!

Robotic surgery for the thyroid was developed largely in South Korea and brought to the United States several years ago as a “tool” in thyroid surgery. Its proposed benefits were to be the following:

Absent or less noticeable neck incisions
Improved visualization
Less Surgeon Fatigue

Although we have been trained and performed robotic thyroid surgery, the following is the reality of robotic thyroid surgery:

Incisions are tremendously longer but just not located on the front of the neck
In anaplastic thyroid cancer, it is the wrong surgery! You risk spilling the cancer!
Anaplastic thyroid cancer that is able to undergoe surgery, must also have immediate post surgical chemotherapy and radiation therapy. The radiation treatment field would have to include the entire area of surgery from underneath the arm to the entire neck. This should never be done!
In anaplastic thyroid cancer there is only one chance for surgery and this is the wrong surgery!!
Multiple surgeons are required
The surgeon has no ability to “feel” in the neck. The fingers are the surgeon’s third eye. Subtle changes in feel, hardness or extension of cancer can be totally unappreciated.
It is not minimally invasive by any measure. It is maximally invasive but just at a distance from where the surgery is focusing.
It is a much longer surgical procedure by any measure (the set up of the robot is longer than the average thyroid lobectomy).
It is an inferior surgical approach to manage anaplastic thyroid cancer
Unanticipated findings during surgery may not be able to be adequately addressed robotically.
It may be an acceptable surgical approach for clearly known benign thyroid surgery. Anaplastic thyroid cancer is one of the most aggressive cancers known to mankind!

Most importantly, the ability to perform a surgery well, is not an indication for a surgery!!! Robotic thyroid surgery is never indicated in managing anaplastic thyroid cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer.

What is the Role of External Beam Radiation Therapy for Anaplastic thyroid cancer?

Anaplastic thyroid cancer treatment with external beam radiation therapy is always indicated if the thyroid cancer team is truly trying to control the cancer. The planning and implementation of radiation therapy is beyond the goals for this website. However certain principles must be emphasized. There are three types of anaplastic thyroid cancer radiation therapy:

1) Definitive Treatment
1. This is a curative approach
2. Following anaplastic thyroid cancer surgery with complete removal of all disease with radiation therapy begun within two weeks following surgery
3. In these circumstances, the anaplastic thyroid cancer patient must have undergone surgery which completely removed the anaplastic thyroid cancer.
4. Whenever feasible, anaplastic thyroid cancer patients should be reduced down to microscopic remaining neck disease, at most, also sparing voice box and swallowing tube function.
5. Radiation therapy given to the neck and upper chest area for approximately 6 ½ weeks
6. chemotherapy used to increase the effectiveness of the radiation therapy
7. This is the only true curative approach to anaplastic thyroid cancer
2) Palliative full course chemotherapy and radiation therapy
1. Radiation therapy given to the neck and upper chest area for approximately 6 ½ weeks
2. chemotherapy used to increase the effectiveness of the radiation therapy
3. Anaplastic thyroid cancer treatment approach when no meaningful surgery is feasible or patient has known anaplastic thyroid cancer distant spread of disease.
3) Palliative high dose radiation therapy (just an attempt to make the remainder of life better)
1. In some instances of anaplastic thyroid cancer, the thyroid cancer team may believe that the distant spread of the anaplastic thyroid cancer may be the greatest risk to the patient. In such circumstances, four high dose treatments of radiation therapy may be utilized to “slow down” the anaplastic thyroid cancer in the neck growth. This is called “quad shot” radiation therapy and is given during a one week period of time.
2. If surgery is not meaningful or feasible, then radiation therapy is given to attempt to slow down the anaplastic cancer’s growth in the neck. As a general rule, choosing to treat a anaplastic thyroid cancer with external beam radiation is a commitment that the surgeon believes that no meaningful surgery will be feasible in the future and therefore radiation therapy is required to help control the anaplastic thyroid cancer (microscopic or gross disease) remaining in the neckAnaplastic thyroid cancer radiation therapy is also associated with significant short term and long term complications and effects that should not be taken lightly.

Editors Note: Whenever feasible, anaplastic thyroid cancer patients should be reduced down to microscopic remaining neck disease, at most, also sparing voice box and swallowing tube function. In the presence of known distant spread of anaplastic thyroid cancer, there is essentially no indication for surgery. When choosing to treat an anaplastic thyroid cancer with external beam radiation and chemotherapy, there is no retreatment or possibility of further surgery. This combined treatment of anaplastic thyroid cancer with chemotherapy and radiation is quite effective in controlling microscopic remaining anaplastic thyroid cancer in the neck following complete surgery. Anaplastic thyroid cancer chemoradiation therapy is also associated with significant short term and long term complications and effects that should not be taken lightly. Anaplastic thyroid cancer should be managed in an interdisciplinary program with experience in managing these cancers.

Why Are Anaplastic Thyroid Cancers Treated with Combination Radiation Therapy and Chemotherapy to the Neck?

Invade (grow into) the voice box (larynx), breathing tube (trachea) or swallowing tube (esophagus)
Directly grow into the skin or deep structures in the neck
Invade the tissues underneath the breast bone (sternum)
are deemed unable to undergo another surgery if their cancer should return.

Anaplastic Thyroid Cancer is Treated with Radiation Therapy for Distant Spread when it:

Has spread to the spinal column and risks the spinal cord itself
Has spread to the brain
Has spread to bone and are causing pain or growth would place the bone at risk for fracture.

Anaplastic thyroid cancer Treatment for Recurrent/Persistent and Metastatic Disease:

Targeted Therapy and/or Chemotherapy

For anaplastic thyroid cancer patients who have spread of their cancer to several places outside of the neck area and other treatments are not helpful or the cancer sites are getting bigger, new therapies have been developed and approved by the FDA (Food and Drug Administration). Although these FDA approved thyroid cancer targeted medications have been shown to be effective, none of these treatments are curative. Skilled physicians in prescribing these medications are required because of the necessity for close monitoring of symptoms, toxicities, and monitoring of the patient’s anaplastic thyroid cancer.

The two approved targeted therapies (medication pills) in the management of thyroid cancer are Lenvima and Sorafenib. These medications are taken by mouth and frequently cause weight loss, fatigue, muscle wasting, hand and foot pain, changes in blood pressure and skin symptoms. The toxicities are directly related to the dose and frequency the medication is taken. Again, these medications cannot be taken indefinitely and do not cure thyroid anaplastic thyroid cancer.

Anaplastic thyroid cancer chemotherapy is rarely indicated except when used in combination with radiation therapy. Experimental therapies such as new targeted therapies, immune therapy based treatments, and other novel approaches for anaplastic thyroid cancer should be developed in institutions directed and capable of performing such investigational studies.

Anaplastic thyroid cancer Treatment with Radioactive Iodine (RAI)

Anaplastic thyroid cancer, itself, is very rarely treated with RAI treatment. RAI treatment is a type of internal radiation therapy. RAI treatment was the first true “targeted therapy” developed in the treatment of cancer. Most anaplastic thyroid cancer have lost the ability to take up iodine like normal thyroid cells. Although radioactive iodine can be considered in the treatment of anaplastic thyroid cancer, it should fall very far behind any other therapies due to the exquisitely high likelihood of little to no benefit of RAI intervention.

Don’t forget, RAI for anaplastic thyroid cancer can also only be considered in the rare circumstance that all of the thyroid gland and anaplastic thyroid cancer in the neck has been completely removed.

Preparation for Radioactive Iodine Treatment

Thyroid anaplastic thyroid cancer patients must be taken off of levothyroxine thyroid hormone (T4 hormone) for a minimum of four weeks, taken off of liothyrionine thyroid hormone (T3 hormone) for a minimum of two weeks, or receive a medication which is TSH (which is a pharmaceutical production of the Thyroid Stimulating Hormone [TSH] produced as a recombinant protein which is identical to the TSH normally produced by the pituitary gland). Additionally, anaplastic thyroid cancer patients must be on a low iodine diet for a minimum of four weeks to starve their body of iodine. Those patients which have undergone CAT scans with intravenous contrast must wait until their blood iodine levels have been adequately decreased (usually at least two months). Note, a desire to treat with radioactive iodine should never prevent the use of necessary CAT scans for the evaluation of a anaplastic thyroid cancer patient.

What are the potential risks of RAI treatment?

Dry mouth and or eyes
Narrowing of the drainage duct of the eye’s tears leading to excessive tearing down the cheek
Decreased production of blood cells by the bone marrow (with very high RAI doses)
Swelling in your cheeks from inflammation or damage to the saliva producing glands (the spit glands)
Short term changes to taste and smell (usually resolve in 4-8 weeks)
Lowered testosterone levels in males (usually resolves within the first year)
Change in periods (menstruation) in women (usually resolves within the first year)
Second tumors (these are rare and can be discussed with your thyroid cancer treatment team)

Thyroid Hormone Suppressive Therapy for Anaplastic thyroid cancer

Thyroid hormone is a necessary hormone for life. The thyroid gland normally produces thyroid hormone to adequate levels. The amount of thyroid hormone produced by the body is strictly controlled by a portion of the brain called the pituitary gland. When the body has too little thyroid hormone, the pituitary gland senses the low levels and produces TSH (thyroid stimulating hormone). When thyroid hormone levels are elevated (too high), the pituitary does the opposite and lowers its production of TSH. This is called an endocrine feedback loop.

Because most anaplastic thyroid cancer cells do not have a site on their surface that is stimulated for growth like all normal thyroid cells with thyroid stimulating hormone, there is little to no potential benefit of “thyroid hormone suppressive therapy”. This site is called a “receptor” and when stimulated by TSH (thyroid stimulating hormone) in normal thyroid cells it causes increased production of thyroid hormone. In anaplastic thyroid cancer cells, this same TSH receptor has usually been lost in the development of the cancer. Therefore, thyroid hormone levels likely have no role in controlling or suppressing the growth of anaplastic thyroid cancers.