Papillary Thyroid Cancer Treatment

Papillary Thyroid Cancer Surgery

Papillary thyroid cancer surgery is introduced here. The correct operation depends upon the papillary thyroid cancer, patient evaluation, and surgeon's expertise. Virtually all patients should have one (and only one) operation! That surgery can frequently be a minimally invasive surgery. What is most important, is that all of the papillary thyroid cancer is removed from the neck in this initial surgery!

For papillary thyroid cancer (and all of the different types (variants) of papillary thyroid cancers that exist within this group), surgery, by far, is the most common first treatment. In fact, papillary thyroid cancer surgery is not only the first treatment but is commonly the only treatment that may be indicated. It is critical that a highly experienced surgeon and the right surgery is obtained the first time. Papillary thyroid cancer surgery should only be done by expert surgeons. By choosing the right surgeon and surgery, you are cured. The wrong choice may lead to repeated surgeries, complications, and even worse! (Sosa JA, Bowman HM, et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg. 1998 Sep;228(3):320-30)

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, papillary thyroid cancer surgery may be considered an art form in its own right.

Papillary thyroid cancer surgery must be considered in several different lights when you think about the neck. Surgery of the thyroid gland itself and surgery for the lymph nodes of the neck. The basic concept is however very simple, remove all of the cancer.

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 an inch in length unless the thyroid mass requires a longer length to allow it to be "delivered". All of the critical structures on the side of the removed thyroid lobe are maintained including both parathyroid glands (the glands that control the calcium) and the nerves that provide movement and sensation to the voice box. The lymph nodes along the side and beneath the thyroid gland are also examined during this surgery to make sure that they are not cancerous as well. Editors note: A thyroid lobectomy is generally not recommended when there are nodules present in both sides of the thyroid gland (both lobes possessing nodules).

• 1. A very effective surgical treatment for small to intermediate size (up to 4 cm or 1.75 inch) papillary thyroid cancers
• 2. Small cosmetic incision design
• 3. Essentially little to no risk of hypoparathyroidism (low blood calcium)
• 4. Outpatient surgical procedure
• 5. Return to normal aerobic activities and daily functions in 24 hours.
• 6. No heavy lifting for three weeks
• 7. Remaining thyroid tissue facilitates ease in thyroid hormone regulation.
• 8. The papillary thyroid cancer cannot be effectively monitored by measuring Thyroglobulin levels.
• 9. Only one nerve to the voice box is even at theoretical risk of injury.

Advantages of Partial Thyroid Removal of Thyroid

Disadvantages of Partial Thyroid Removal for Thyroid Cancer

Total Thyroidectomy

In this surgery, the entire thyroid gland is removed. A small incision in the lower neck is required which is about an inch in length unless the thyroid mass requires a longer length to allow it to be "delivered". The length of a total thyroidectomy incision is no longer than an incision for a thyroid lobectomy. All of the critical structures on both sides of the thyroid are maintained including all four parathyroid glands and all four nerves that provide movement (recurrent laryngeal nerves) and sensation to the voice box (superior laryngeal nerves). The lymph nodes along the side and beneath the thyroid gland are also examined during this surgery to make sure that they are not cancerous as well.

Advantages of Total Thyroidectomy for Thyroid Cancer

Papillary 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 can be performed initially when the thyroid gland is removed in the treatment of papillary thyroid cancer or following the initial surgery in the less common circumstances when papillary thyroid cancer recurs or persists. The central compartment lymph node surgery spares all critical structures including the nerves to the voice box and all parathyroid glands not directly involved by cancer. 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 papillary thyroid cancer, the central compartment lymph nodes are at risk of containing cancer in up to 50% of patients. That risk increases with the size of the papillary 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. Here, the arrow points to an abnormal lymph node seen on ultrasound next to the thyroid gland before surgery. Abnormal lymph nodes undergo fine needle aspiration (FNA) examination to determine whether cancer is present. Some lymph nodes which lay immediately underneath the thyroid gland cannot be seen until the time of surgery and required a skilled surgeon to identify them and can then be confirmed during the surgery by a process called frozen section pathology. Warning: The linked video here is a video of an actual thyroid surgery up close, so if you are in any way squeamish about seeing an actual surgery in progress please do not follow this link! Video: Tiny Discoveries During Thyroid Surgery Result in Big Changes
• If papillary thyroid cancer is determined to be present in central compartment lymph nodes at any time in a patient's lifetime, an expert surgeon who does this surgery routinely is needed to remove the lymph nodes in the central compartment, on both sides) and spare the nerves to the voice box and the critical glands that control calcium (parathyroid glands).
• In larger papillary thyroid cancers which are greater than one inch or have grown outside of the capsule of the thyroid, removal of the lymph nodes of the central compartment on the side of the cancer should be done routinely since:
  1. The nerve to the voice box (recurrent laryngeal nerve) has already, by necessity from the thyroid surgery itself, been significantly identified along most of its course and another surgery on the same side would be more difficult because of scarring and this subsequent surgery would put the nerve to the voice box at high risk for injury.
  2. The risk of microscopic lymph node metastasis is approximately 50%.

Extended or Complicated Thyroidectomy

Papillary thyroid cancer may sometimes be more aggressive than ultrasound or CT imaging suggested prior to undergoing surgery. In these cases, an expert surgeon that recognizes those "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, occasional thyroid surgeons are commonly unprepared to perform the appropriate surgery and a subsequent surgery for persistent disease will be required.

Papillary 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 papillary 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 in instances where an ultrasound with fine needle aspiration has confirmed papillary thyroid cancer spread to lymph nodes in the side of the neck
• The papillary thyroid cancer anterolateral neck dissection is not the same neck dissection as for other cancers that occur in the neck. Papillary thyroid cancer spreads 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 papillary thyroid expert surgeon trained and experienced to perform modified neck dissections specifically for thyroid cancer is needed to prevent recurrent or persistent disease.
• The anterolateral neck dissection, in skilled hands, spares all critical nerves, muscles, and blood vessels which are not directly involved with cancer (very rarely are critical structures involved by papillary thyroid cancers). It ads (additional) approximately 40 minutes of surgery to remove the lymph nodes and fatty tissue.

Right next dissection for Thyroid Cancer

Papillary Thyroid Cancer Surgery in Sites Other Than The Neck

Papillary 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 papillary 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 papillary thyroid cancer distant disease located?
• What are the risks and benefits of surgery?
• Are there other sites of distant spread?
• What papillary thyroid cancer treatments have already been used?
• What were the outcomes of other treatments for the papillary thyroid cancer?
• How fast is the papillary thyroid cancer growing?
• What are the patient's treatment desires?
• What are the other treatment options?
• What is the papillary thyroid cancer pathologic type (what do the cells look like under the microscope?
• What are the papillary thyroid cancer genetic mutations?

Papillary Thyroid Cancer Robotic Surgery

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 papillary thyroid cancer, it is a one sided surgery approach to a frequently required two-sided surgery!
• The instruments used to perform the surgery are not as refined or delicate as the instruments used to perform the minimally invasive neck surgeries. (think of all the delicate structures that we have shown you here)
• 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 papillary 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.

Most importantly, the ability to perform a surgery well is not an indication for a surgery! Robotic thyroid surgery is an inferior surgical approach in managing papillary thyroid cancer, any other type of thyroid cancer, or any thyroid lesion at risk of being a potential thyroid cancer.

Papillary Thyroid Cancer Treatment with Radioactive Iodine (RAI)

Papillary thyroid cancer, itself, is not an indication for 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. The papillary thyroid cancer patient swallows a radioactive iodine form of iodine called iodine 131 (I-131) in a liquid or pill (capsule) form. The RAI is absorbed through digestion and circulated throughout the body in the bloodstream. Papillary thyroid cancer cells can pick up the radioactive iodine wherever they are located in the body.

If you had a papillary thyroid cancer 25 years ago, you would have almost certainly been treated with surgery and RAI. Today, only approximately 20% of all papillary thyroid cancer patients undergo post-0perative RAI treatment. RAI therapy is primarily beneficial only when the papillary thyroid cancer patient has undergone a total thyroidectomy (complete removal of the thyroid gland) for their papillary thyroid cancer.

Papillary thyroid cancer should only undergo RAI treatment (therapy) in instances where the risk of the papillary thyroid cancer coming back is greater than the potential risks of RAI therapy itself. In papillary thyroid cancer treatment, there is no urgency for the rapid delivery of RAI. RAI can be given as early as 4-5 weeks following total thyroidectomy but can be delayed for months or even years following surgery.

Preparation for Radioactive Iodine Treatment

Papillary 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, papillary 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 papillary thyroid cancer patient.

The potential risks of RAI treatment include:

• 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)

Papillary Thyroid Cancer Treatment With RAI (Radioactive Iodine): How and How Much Treatment?

Papillary thyroid cancer guidelines for post operative treatment with radioactive iodine were last updated in the American Thyroid Association 2016 edition. After your doctor has prepared your body for RAI by either stopping your use of thyroid hormone pills or giving injections of recombinant TSH (Thyrogen), they may choose to give you a small dose of RAI and perform a special nuclear scan called a Thyroid Cancer Uptake Study. In this scan, the image will determine if there is any evidence of iodine uptake in the body. Approximately 90% of patients will have some uptake of iodine following a total thyroidectomy. Papillary thyroid cancer is not the only reason that iodine can be taken up by tissue. One such issue is retained thyroid tissue. How much retained thyroid tissue is related to the thoroughness of your thyroid surgeon in performing a total thyroidectomy. The amount of RAI chosen to treat the papillary thyroid cancer is based upon:

• The level of thyroglobulin while the TSH is elevated for the scan (this is called a stimulated thyroglobulin)
• The percent uptake of RAI in the Thyroid Cancer Uptake Scan
• The papillary thyroid cancer locations of disease (uptake)
• Prior RAI treatment doses

As an alternative to a thyroid cancer uptake study of a small dose of RAI, some doctors may choose to give you their prescribed dose of RAI as a definitive treatment. Following either of the above approaches to treat a papillary thyroid cancer with RAI, a scan is obtained following the therapeutic dose in 48 to 72 hours to determine the location and percent uptake of the radioactive iodine. The strength of radioactive iodine is described in millicuries. The papillary thyroid cancer treatment dose of radioactive iodine ranges from about 30 millicuries to approximately 150 millicuries. Low risk papillary thyroid cancers and eradication of small amounts of retained thyroid tissue are treated with lower doses of RAI in the 30-50 range. Intermediate risk papillary thyroid cancers such as patients above 50 years of age with lymph node spread are treated in the middle ranges. Papillary thyroid cancers with high risk features or distant spread of disease are treated with higher doses in the 150 millicurie range. (Haugen BR, Alexander EK, et al. American Thyroid Association Management Guidelines for Adult patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan. 26 (1):1-133)

Papillary thyroid cancers can also be treated with radioactive iodine based upon a method called dosimetry. This is a radiation physics determination, utilizing complex mathematical methods to determine the actual dose of radiation that will be delivered to a particular area of papillary thyroid cancer. In some circumstances, dosimetry can allow much higher doses of radioactive iodine to be prescribed when papillary thyroid cancers effectively take up the treatment. Papillary thyroid cancers, however, rarely require dosimetry for definitive treatment.

Thyroid Hormone Suppressive Therapy for Papillary 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.

Most papillary thyroid cancer cells and all normal thyroid cells have a site on the surface of the cell that can stimulate their growth. 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 papillary thyroid cancer cells, this same TSH receptor can stimulate the growth of these cancer cells. Obviously, it is an undesirable concept to have TSH stimulate papillary thyroid cancer cells to grow. Therefore, the goal in the papillary thyroid cancer patient is to keep TSH levels low. So how is this done?

When papillary thyroid cancer patients take thyroid hormone pills, the body does not tell the difference between this medication and what the thyroid gland produces. The more thyroid hormone circulating in your body causes the TSH production to drop. Therefore, papillary thyroid cancer patients are usually given thyroid hormone to decrease TSH levels to prevent the growth of the cancer cells. Giving thyroid hormone to papillary thyroid cancer patients is called thyroid hormone suppressive therapy when the goal is to decrease the pituitary production of TSH. Papillary thyroid cancer patients that have thyroid suppressive therapy will have TSH levels that are below the "normal range". To those that are caring for papillary thyroid cancer patients but unfamiliar with the concept of thyroid suppressive therapy, they may mistake the dose of thyroid hormone for being "too high". Thyroid suppressive therapy is a delicate balance between elevated but not "too high" thyroid hormone doses. It is therefore important that only your skilled papillary thyroid cancer specialist manage your thyroid hormone. But it is also important that communication be open between your papillary thyroid cancer specialist and those that are caring for your primary care needs.

External Beam Radiation Therapy for Papillary Thyroid Cancer

Papillary thyroid cancer treatment with external beam radiation therapy is not commonly required or indicated. The planning and implementation of radiation therapy is beyond the goals for this website. However certain principles must be emphasized. Radiation therapy is not a substitute for incomplete surgery. What is meant by that is all the papillary thyroid cancer in the neck must be completely and effectively removed. Whenever feasible, papillary thyroid cancer patients should be reduced down to microscopic remaining neck disease, at most, also sparing voice box and swallowing tube function. Radiation therapy should not be given as a substitute for incomplete surgery. As a general rule, choosing to treat a papillary thyroid cancer with external beam radiation is a commitment that the surgeon believes that no meaningful re-operation will be feasible in the future and therefore radiation therapy is required to help control the papillary thyroid cancer (microscopic disease) remaining in the neck. In these circumstances, external beam radiation therapy is quite effective. Papillary thyroid cancer radiation therapy is also associated with significant short term and long term complications and effects that should not be taken lightly. (Schwartz DL, Lobo MJ et al. Postoperative external beam radiotherapy for differentiated thyroid cancer: outcomes and morbidity with conformal treatment. Int J Radiat Oncol Biol Phys. 2009 Jul 15;74(4):1083-91)

Papillary Thyroid Cancer Treatment for Persistent or Recurrent Disease:

Papillary thyroid cancer treatment for recurrences (cancer that has come back) or persistence (cancer that remains after initial therapy) depends mainly on where the cancer is, although other factors may be important as well. The recurrence may be found by either thyroglobulin blood tests or imaging studies such as ultrasounds, radioiodine scans, CAT scan or PET imaging.

If there is concern that the papillary thyroid cancer has come back in the neck, an ultrasound-guided biopsy is first done to confirm that it is really cancer. Then, if the papillary thyroid cancer appears to be resectable (removable), surgery is often used. The extent of surgery would depend upon the location or locations of the persistent or recurrent papillary thyroid cancer and the prior surgeries and quality of surgeries that the patient has undergone. The sections of central compartment surgery and lateral neck dissection have been written for you and are appropriate for persistence or recurrent papillary thyroid cancer in either of those locations. We have examples of surgeries for just these types of circumstances for you to watch. Papillary thyroid cancer surgery very effectively manages neck disease, sparing function and cosmetic appearance but should only be performed by very high volume and experienced papillary thyroid cancer surgeons. We have publications establishing our ability to control papillary thyroid cancer recurrences or persistence in the neck approaching 98% in both (either) of these areas of the neck lymph nodes. (Tufano RP, Clayman GL, et al. Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of surgical intervention versus active surveillance. Thyroid. 2015 Jan;25(1):15-27)

Persistent or recurrent papillary thyroid cancer in residual thyroid tissue is much more concerning for the potential for the cancer to extend directly into the breathing tube or voice box. Only the most skilled and experience thyroid cancer surgeons should manage such circumstances. The purpose of this specific papillary thyroid cancer surgery is to maintain vocal and swallowing function, parathyroid function, and airway control. These are the most complicated and complex of all thyroid surgeries.

If the papillary thyroid cancer shows up on a radioiodine scan (meaning the cells are taking up iodine), radioactive iodine (RAI) therapy may be used, either alone or with surgery. If the papillary thyroid cancer does not show up on the radioiodine scan but is found by other imaging tests such as an ultrasound, CAT scan, or PET scan, the papillary thyroid cancer is termed non-radioiodine avid. The papillary thyroid cancer treatment will be based upon interdisciplinary evaluation, disease locations and extent of disease.

Targeted Therapy and/or Chemotherapy

For papillary thyroid cancer patients who have spread of their cancer to several places outside of the neck area and RAI 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 papillary 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 papillary thyroid cancer.

The two approved targeted therapies (medication pills) in the management of papillary 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 the papillary thyroid cancer.

Papillary thyroid cancer chemotherapy is rarely indicated except when used in combination with radiation therapy for the worst of the worst types of thyroid cancers growing into the breathing tube or swallowing tube. Experimental therapies such as new targeted therapies, immune therapy based treatments, and other novel approaches for papillary thyroid cancer should be developed in institutions directed and capable of performing such investigational studies.