| 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] |
| 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] |
| 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] |
| 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. |
| 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] |
| 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] |
| 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] |
| 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] |