History

Fact Explanation
Asymptomatic Some patients with papillary thyroid carcinoma (PTC) are asymptomatic. Papillary carcinoma is common in patients in their thirties and forties. [1,4]
Anterior neck mass Some patients may present with the complain of a nodule or mass in the anterior neck. PTC is a very slow growing tumor and some patients may complain of a thyroid nodule of very long duration and some may not have noticed any enlargement. Massive enlargement of the thyroid nodule can be seen in patients who have neglected the initial appearance and the enlargement of the gland. [1]
Respiratory symptoms Patients may complain of cough, difficulty in breathing and rarely hemoptysis. This is due to the compression of the airway due to the enlarged thyroid gland. Hemoptysis can occur secondary to pulmonary metastases as well. [4,5]
Difficulty in swallowing Compression of the esophagus by the tumor causes difficulty in swallowing. Rarely esophageal musculature can be invaded by the tumor cells resulting progressive dysphagia. [5]
Neck pain Some patients with PTC may complain of pain in the neck. [4]
Stridor [4] Patients develop stridor due to the tumor invasion and paralysis of the recurrent laryngeal nerve.
Bone pain Intractable back pain is indicative of bone metastases. [1]
Symptoms of cerebral metastases Cerebral metastases are very rare in patients with PTC. However early morning severe headache with associated nausea, vomiting and visual disturbances are suggestive of cerebral metastases. [2]
History of neck irradiation Neck irradiation is a risk factor for the development of carcinoma of the thyroid particularly PTC. [3,4]
Family history of thyroid carcinoma Some patients have a positive family history of thyroid carcinoma. [3]
History of thyroid disease Patients with a history of dyshormonogenetic goiter and congenital hypothyroidism are at risk of PTC. [4]
Incidentaloma Thyroid nodules of less than 1cm is detected with imaging techniques (CT, ultrasound scan) mainly PET scan. Solitary incidentalomas need further investigations particularly assessment of cytology. [6,7]
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. OTA T.. Papillary Carcinoma of the Thyroid with Distant Metastases to the Cerebrum: a Case Report. [online] 2001 March, 31(3):112-115 [viewed 21 July 2014] Available from: doi:10.1093/jjco/hye023
  3. PACINI F., CASTAGNA M. G., BRILLI L., PENTHEROUDAKIS G.. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 21(Supplement 5):v214-v219 [viewed 22 July 2014] Available from: doi:10.1093/annonc/mdq190
  4. ERDEN ERSIN SUKRU, BABAYIGIT CENK, DAVRAN RAMAZAN, AKIN MUSTAFA, KARAZINCIR SINEM, ISAOGULLARI NEBIHE, DEMIRKOSE MESUT, GENC SEBAHAT. Papillary Thyroid Carcinoma with Lung Metastasis Arising from Dyshormonogenetic Goiter: A Case Report. Case Reports in Medicine [online] 2013 December, 2013:1-4 [viewed 22 July 2014] Available from: doi:10.1155/2013/813167
  5. SEOUNG HG, KIM JH, CHOI JC, KIM SM, KIM SS, KIM BH, KIM IJ, SONG GA, KIM GH. A Case of Papillary Thyroid Cancer Recurring as an Esophageal Submucosal Tumor Chonnam Med J [online] 2012 Apr, 48(1):60-64 [viewed 22 July 2014] Available from: doi:10.4068/cmj.2012.48.1.60
  6. ENG CY, QURAISHI MS, BRADLEY PJ. Management of Thyroid nodules in adult patients Head Neck Oncol [online] :11 [viewed 22 July 2014] Available from: doi:10.1186/1758-3284-2-11
  7. PAMPALONI MIGUEL HERNANDEZ, WIN AUNG Z.. Prevalence and Characteristics of Incidentalomas Discovered by Whole Body FDG PETCT. International Journal of Molecular Imaging [online] 2012 December, 2012:1-6 [viewed 22 July 2014] Available from: doi:10.1155/2012/476763

Examination

Fact Explanation
Examination of the thyroid gland A firm, and non-tender solitary nodule with ill-defined borders can be palpated in PTC. The nodule moves with swallowing and otherwise non-mobile. [1,3]
Presence of enlarged cervical lymph nodes Cervical lymph node metastases can be clinically detected if the lymph nodes are palpable. PTC commonly spreads via lymphatics but hematogenous spread is rare. About 78% of the patients with PTC have lymph node spread at the time of presentation. Enlarged lateral deep cervical lymph nodes are commonly palpated in patients with PTC in which level III nodes are the most frequently palpated. [1,6]
Laryngoscope Vocal cord paralysis can be diagnosed by the laryngoscope. [4]
Focal neurological signs Patients with cerebral metastases can have focal neurological signs. [1,2]
Papilledema Opthalmoscopic examination is helpful in detecting papilledema secondary to increased intra-cranial pressure. [1,2]
Hepatomegaly Although rare, hematogenous spread to the liver causes hepatomegaly. [1]
Evidence of bone metastasis Bone metastasis of the spine produces tender points. Vertebral collapse is detected by palpation of the vertebral column. [1]
Range of neck movements Range of neck movements should be assessed in patients with large goiters as a part of the pre-anesthetic evaluation of the patient. [5]
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. OTA T.. Papillary Carcinoma of the Thyroid with Distant Metastases to the Cerebrum: a Case Report. [online] 2001 March, 31(3):112-115 [viewed 21 July 2014] Available from: doi:10.1093/jjco/hye023
  3. PACINI F., CASTAGNA M. G., BRILLI L., PENTHEROUDAKIS G.. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 21(Supplement 5):v214-v219 [viewed 22 July 2014] Available from: doi:10.1093/annonc/mdq190
  4. ERDEN ERSIN SUKRU, BABAYIGIT CENK, DAVRAN RAMAZAN, AKIN MUSTAFA, KARAZINCIR SINEM, ISAOGULLARI NEBIHE, DEMIRKOSE MESUT, GENC SEBAHAT. Papillary Thyroid Carcinoma with Lung Metastasis Arising from Dyshormonogenetic Goiter: A Case Report. Case Reports in Medicine [online] 2013 December, 2013:1-4 [viewed 22 July 2014] Available from: doi:10.1155/2013/813167
  5. BAJWA SUKHMINDER JITSINGH, SEHGAL VISHAL. Anesthesia and thyroid surgery: The never ending challenges. Indian J Endocr Metab [online] 2013 December [viewed 22 July 2014] Available from: doi:10.4103/2230-8210.109671
  6. LEE BYUNG-JOO, WANG SOO-GEUN, LEE JIN-CHOON, SON SEOK-MAN, KIM IN-JU, KIM YONG-KI. Level IIb Lymph Node Metastasis in Neck Dissection for Papillary Thyroid Carcinoma. Arch Otolaryngol Head Neck Surg [online] 2007 October [viewed 22 July 2014] Available from: doi:10.1001/archotol.133.10.1028

Differential Diagnoses

Fact Explanation
Goiter Diffuse goiter is commoner. Patients may have features of hypo or hyperthyroidism or may be euthyroid. Some patients present with a solitary nodule. [2]
Hyperthyroidism Presence of a 'cold' nodule in a patient with hyperthyroidism should raise the suspicion of thyroid malignancy. However the occurrence of thyroid cancer in hyperthyroid patients is rare. [3]
Parathyroid Carcinoma Patients present with symptoms of hypercalcemia (Eg: Nausea, vomiting, loss of appetite, thirst, constipation and abdominal pain) or may be asymptomatic. [4]
Thyroid Lymphoma Primary thyroid lymphoma is a rare disease and it is has similar features of anaplastic thyroid carcinoma. The differentiation of the two is made by cytological examination. [5]
Thyroid Nodule A solitary nodule may be incidental or asymptomatic. Exclusion of a malignancy is a major concern. [6]
Follicular adenomas and carcinomas FNAC will help in diagnosing the two but it won't be able to differentiate the two. [7]
Medullary Carcinoma of the thyroid Patients present with a palpable neck mass. Fine needle aspiration and cytology (FNAC) will provide the cytological diagnosis. [8]
Secondary deposits of a malignancy Thyroid gland is a possible site of metastasis. Lung, breast, kidney, skin, adrenal glands, liver and meninges are primary sites of the tumor which can metastasize to the thyroid gland. [12]
Hurthle cell carcinoma Hurthle cell carcinoma is a subtype of follicular cell carcinoma. The presentation can vary from a low grade, slow growing tumor to more aggressive tumor with distant metastases. [10]
Anaplastic carcinoma of the thyroid Anaplastic thyroid carcinomas are rare, rapidly growing thyroid carcinomas with early and wide-spread metastases, which have worse prognosis of all types of thyroid carcinomas. [9]
Branchial cleft cysts [1] This is a congenital cause of lateral neck mass. Abnormalities of the second branchial arch is the most common cause of branchial cleft cysts. [11]
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. MARK P. J. V. The epidemiology of thyroid disease. Br Med Bull [online] (2011) 99 (1): 39-51. [viewed 22 July 2014] Available from: doi: 10.1093/bmb/ldr030
  3. GABRIELE R, LETIZIA C, BORGHESE M, DE TOMA G, CELI M, IZZO L, CAVALLARO A. Thyroid cancer in patients with hyperthyroidism. Horm Res [online] 2003, 60(2):79-83 [viewed 22 July 2014] Available from: doi:71875
  4. RICCI GABRIELE, ASSENZA MARCO, BARRECA MARCO, LIOTTA GIANLUCA, PAGANELLI LIVIO, SERAO ANGELO, TUFODANDRIA GIOVANNI, MARINI PIERLUIGI. Parathyroid Carcinoma: The Importance of High Clinical Suspicion for a Correct Management. International Journal of Surgical Oncology [online] 2012 December, 2012:1-5 [viewed 22 July 2014] Available from: doi:10.1155/2012/649148
  5. WIDDER S, PASIEKA JL. Primary thyroid lymphomas. Curr Treat Options Oncol [online] 2004 Aug, 5(4):307-13 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15233907
  6. HEGEDüS LASZLO. The Thyroid Nodule. N Engl J Med [online] 2004 October, 351(17):1764-1771 [viewed 22 July 2014] Available from: doi:10.1056/NEJMcp031436
  7. MCHENRY CR, PHITAYAKORN R. Follicular Adenoma and Carcinoma of the Thyroid Gland Oncologist [online] 2011 May, 16(5):585-593 [viewed 22 July 2014] Available from: doi:10.1634/theoncologist.2010-0405
  8. PINCHOT SN, KUNNIMALAIYAAN M, SIPPEL RS, CHEN H. Medullary Thyroid Carcinoma: Targeted Therapies and Future Directions J Oncol [online] 2009:183031 [viewed 22 July 2014] Available from: doi:10.1155/2009/183031
  9. SUN M.L., SANG J.S., BYOUNG C.C. Treatment Outcome of Patients with Anaplastic Thyroid Cancer: A Single Center Experience. Yonsei Med J. [online] Mar 1, 2012; 53(2): 352–357. [viewed 22 July 2014] Available from: doi: 10.3349/ymj.2012.53.2.352
  10. HANIEF MR, IGALI L, GRAMA D. H?rthle cell carcinoma: diagnostic and therapeutic implications World J Surg Oncol [online] :27 [viewed 22 July 2014] Available from: doi:10.1186/1477-7819-2-27
  11. LONG K. L., SPEARS C., KENADY D. E.. Branchial cleft cyst encircling the hypoglossal nerve. Journal of Surgical Case Reports [online] December, 2013(9):rjt068-rjt068 [viewed 22 July 2014] Available from: doi:10.1093/jscr/rjt068
  12. HARCOURT-WEBSTER JN. Secondary neoplasm of the thyroid presenting as a goitre J Clin Pathol [online] 1965 May, 18(3):282-287 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC472925

Investigations - for Diagnosis

Fact Explanation
Thyroid function test Estimation of serum free T4 and thyroid stimulating hormone (TSH) levels is usually normal. [1]
Ultrasound scan of the thyroid gland [3] Ultrasound scan can demonstrate the presence of thyroid nodules and when combined with Doppler it can also demonstrate the increased vascularity of the nodule.
Fine-needle aspiration biopsy [1] FNAB can be done with ultrasound guidance for impalpable lesions. grossly firm mass that is irregular and not encapsulated.
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. PACINI F., CASTAGNA M. G., BRILLI L., PENTHEROUDAKIS G.. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 21(Supplement 5):v214-v219 [viewed 22 July 2014] Available from: doi:10.1093/annonc/mdq190

Investigations - Fitness for Management

Fact Explanation
Chest radiography Chest X-ray is indicated if there is a history of lung disease. [2]
Serum electrolytes and creatinine Renal function should be evaluated prior to the surgery. [1]
Neck X-ray Lateral and antero-posterior neck X-rays are indicated in the pre-anesthetic evaluation of the patient to detect the presence of tracheal stenosis and retro-sternal extension of the goiter. [3]
References
  1. COMMITTEE ON STANDARDS AND PRACTICE PARAMETERS, APFELBAUM JL, CONNIS RT, NICKINOVICH DG, AMERICAN SOCIETY OF ANESTHESIOLOGISTS TASK FORCE ON PREANESTHESIA EVALUATION, PASTERNAK LR, ARENS JF, CAPLAN RA, CONNIS RT, FLEISHER LA, FLOWERDEW R, GOLD BS, MAYHEW JF, NICKINOVICH DG, RICE LJ, ROIZEN MF, TWERSKY RS. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology [online] 2012 Mar, 116(3):522-38 [viewed 22 July 2014] Available from: doi:10.1097/ALN.0b013e31823c1067
  2. MUSKETT AD, MCGREEVY JM. Rational preoperative evaluation. Postgrad Med J [online] 1986 Oct, 62(732):925-928 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2419025
  3. BAJWA SUKHMINDER JITSINGH, SEHGAL VISHAL. Anesthesia and thyroid surgery: The never ending challenges. Indian J Endocr Metab [online] 2013 December [viewed 22 July 2014] Available from: doi:10.4103/2230-8210.109671

Investigations - Followup

Fact Explanation
Serum thyroglobulin levels Estimation of serum thyroglobulin is indicated in monitoring the patients with PTC. Serum levels of thyroglobulin increases in the presence of tumor recurrence. [1,2]
Ultrasound scan of the neck Ultrasound scan of the neck is a non-invasive option in diagnosing recurrent PTC. [2]
Radioisotope scan Radioisotope scan is useful in detecting recurrence of PTC. These remnants and tumor recurrences uptake more radioisotope which is seen in the imaging. [3]
References
  1. GUERRERO MA, CLARK OH. Controversies in the Management of Papillary Thyroid Cancer Revisited ISRN Oncol [online] 2011:303128 [viewed 22 July 2014] Available from: doi:10.5402/2011/303128
  2. BUSAIDY NAIFA LAMKI, CABANILLAS MARIA E.. Differentiated Thyroid Cancer: Management of Patients with Radioiodine Nonresponsive Disease. Journal of Thyroid Research [online] 2012 December, 2012:1-12 [viewed 22 July 2014] Available from: doi:10.1155/2012/618985
  3. SCHNEIDER DAVID F., CHEN HERBERT. New developments in the diagnosis and treatment of thyroid cancer. CA A Cancer Journal for Clinicians [online] December, 63(6):373-394 [viewed 22 July 2014] Available from: doi:10.3322/caac.21195

Investigations - Screening/Staging

Fact Explanation
Ultrasound scan of the neck Ultrasound scan of the neck is recommended for screening of the papillary carcinoma of the thyroid. FNAB can be combined if ultrasound appearance of the nodule is suspicious. [1,3]
MRI scan MRI of the head can detect the presence of cerebral metastases. [2,3]
CT scan CT scan of the neck can be used to assess the local spread of the disease. CT scan of the head is helpful in detecting cerebral metastases. Contrast CT scan of the chest can detect macro- and micronodular pulmonary metastases. CT scan is less useful in detecting tumor recurrences than the ultrasound scan. [2,3]
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. OTA T.. Papillary Carcinoma of the Thyroid with Distant Metastases to the Cerebrum: a Case Report. [online] 2001 March, 31(3):112-115 [viewed 21 July 2014] Available from: doi:10.1093/jjco/hye023
  3. BUSAIDY NAIFA LAMKI, CABANILLAS MARIA E.. Differentiated Thyroid Cancer: Management of Patients with Radioiodine Nonresponsive Disease. Journal of Thyroid Research [online] 2012 December, 2012:1-12 [viewed 22 July 2014] Available from: doi:10.1155/2012/618985

Management - Specific Treatments

Fact Explanation
Radical thyroidectomy Total thyroidectomy is the indicated surgical treatment for PTC. Total thyroidectomy reduced the risk of persistence and recurrence. Thyroid lobectomy and isthmusectomy are alternatives for total thyroidectomy, which have no risk of hypothyroidism. Prophylactic neck dissection can be combined to remove the enlarged lymph nodes. PTC has an excellent prognosis (99.7% five year survival and 93% ten year survival) especially in young (younger than 45 years) females with local disease. [1,2,3,4]
Radioiodine Postoperative occult persistent or metastatic disease is treated with radioactive iodine. This can be done preoperatively to down-stage tumors more than 2cm in size. [2]
Chemotherapy Doxorubicin, taxol, and cisplatin are used in chemotherapy. Chemotherapy is indicated in patients with widespread metastatic disease. [4]
External beam radiotherapy (EBRT) EBRT is effective as an adjuvant therapy to other treatment modalities in preventing loco-regional recurrences of PTC. [4]
Tyrosine kinase inhibitors (TKIs) TKIs are oral immune modulators (Sorafenib, Sunitinib, Pazopanib) which are useful in molecular targeted therapy. [4]
Management of cerebral metastases Surgical resection of single resectable metastases, radioiodine treatment and external beam radiotherapy are available treatment options for the treatment of cerebral metastases. [4]
Management of bone metastases Surgical resection, external beam radiotherapy and gamma knife radiosurgery can be used in the treatment of bone metastases. Intravenous bisphosphonates can be used to treat painful bone metastases. [4]
Conservative management Conservative management of small (less than 1cm) low risk (no evidence of capsular invasion) and well differentiated thyroid carcinoma is also practiced, because of its low risk of regional and locoregional spread. [5]
Management of thyroid incidentaloma Ultrasound scan of the thyroid and FNAB is necessary in the management of thyroid incidentalomas. Abnormal ultrasound scan findings should be further evaluated with FNAB in order to confirm or to exclude the possibility of a thyroid malignancy. If there is no evidence of malignancy regular clinical examination, thyroid function test and ultrasound scan are recommended. [6]
References
  1. SPARTALIS ELEFTHERIOS D., KARATZAS THEODORE, CHARALAMPOUDIS PETROS, VERGADIS CHRYSOVALANTIS, DIMITROULIS DIMITRIOS. Neglected Papillary Thyroid Carcinoma Seven Years after Initial Diagnosis. Case Reports in Oncological Medicine [online] 2013 December, 2013:1-3 [viewed 21 July 2014] Available from: doi:10.1155/2013/148973
  2. GUERRERO MA, CLARK OH. Controversies in the Management of Papillary Thyroid Cancer Revisited ISRN Oncol [online] 2011:303128 [viewed 21 July 2014] Available from: doi:10.5402/2011/303128
  3. ERDEN ERSIN SUKRU, BABAYIGIT CENK, DAVRAN RAMAZAN, AKIN MUSTAFA, KARAZINCIR SINEM, ISAOGULLARI NEBIHE, DEMIRKOSE MESUT, GENC SEBAHAT. Papillary Thyroid Carcinoma with Lung Metastasis Arising from Dyshormonogenetic Goiter: A Case Report. Case Reports in Medicine [online] 2013 December, 2013:1-4 [viewed 22 July 2014] Available from: doi:10.1155/2013/813167
  4. BUSAIDY NAIFA LAMKI, CABANILLAS MARIA E.. Differentiated Thyroid Cancer: Management of Patients with Radioiodine Nonresponsive Disease. Journal of Thyroid Research [online] 2012 December, 2012:1-12 [viewed 22 July 2014] Available from: doi:10.1155/2012/618985
  5. HASSANAIN M, WEXLER M. Conservative management of well-differentiated thyroid cancer Can J Surg [online] 2010 Apr, 53(2):109-118 [viewed 22 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2845956