Treatment of thyroid cancer by type and stage

The type of treatment your doctor will recommend depends on the type and stage of the cancer and on your overall health. This section discusses the typical treatment options for each type and stage of thyroid cancer, but your doctor may have reasons for suggesting a different treatment plan. Don’t hesitate to ask him or her questions about your treatment options.

Papillary carcinoma and its variants

Stages I and II: These cancers are treated with surgery. Most often this is a thyroidectomy, but lobectomy (removal of only the affected side of the thyroid gland) may be an option for some people. Radioiodine treatment is sometimes used after thyroidectomy, but the cure rate with surgery alone is excellent. If the cancer does come back, radioiodine treatment can still be offered.

People who have a thyroidectomy will need to take daily thyroid hormone (levothyroxine) pills. If radioactive iodine treatment is planned, the start of thyroid hormone therapy may be delayed until the treatment is finished (usually about 6 weeks after surgery).

Some doctors recommend central compartment neck dissection (surgical removal of lymph nodes next to the thyroid) along with removal of the thyroid. Although this operation has not been shown to improve cancer survival, it might lower the risk of cancer coming back in the neck area. Because removing the lymph nodes allows them to be checked for cancer under the microscope, this surgery also makes it easier to accurately stage the cancer.

Stages III and IV: Most patients have the thyroid removed (either a near-total or total thyroidectomy) along with nearby lymph nodes. Some doctors recommend central compartment neck dissection (surgical removal of lymph nodes next to the thyroid). Although this has not been shown to improve survival, it might lower the risk of cancer coming back in the neck area. It also makes it easier to accurately stage the cancer. If cancer has spread to other neck lymph nodes, a modified radical neck dissection (a more extensive removal of lymph nodes from the neck) is often done.

Radioiodine therapy is often used to destroy any remaining thyroid tissue after surgery and to try to treat any cancer remaining in the neck or elsewhere in the body that takes up iodine. Distant metastases may need to be treated with external beam radiation therapy, targeted therapy, or chemotherapy if they do not respond to radioactive iodine.

Thyroid hormone therapy is used as well, although it’s not started until after radioiodine treatment.

Recurrent cancer: Treatment of cancer that comes back 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 blood tests or imaging tests such as radioiodine scans.

If the cancer can be located and appears to be resectable (removable), surgery is often used. If the cancer shows up on a radioiodine scan (meaning the cells are taking up iodine), radioiodine therapy may be used, either alone or with surgery. If the cancer does not show up on the radioiodine scan but is found by other imaging tests such as an MRI or PET scan, external radiation may be used.

Targeted therapy or chemotherapy may be tried if the cancer has spread to several places and radioiodine and other treatments are not helpful, but doctors are still trying to find effective drugs for this disease. Because these cancers can be hard to treat, another option is taking part in a clinical trial of newer treatments.

Follicular and Hürthle cell carcinoma

Stages I to IV: Most doctors recommend near-total or total thyroidectomy for these types of thyroid cancer, although lobectomy may be an option for some patients with very early stage cancers.

Thyroidectomy makes radioactive iodine treatment afterward more effective. As with papillary cancer, some lymph nodes usually are removed and examined. If cancer has spread to lymph nodes, a central compartment or modified radical neck dissection (surgical removal of lymph nodes from the neck) may be done. Because the thyroid is removed, patients will need thyroid hormone therapy as well, although it is often not started right away.

Radioiodine scanning is usually done after surgery to look for areas still taking up iodine. Spread to nearby lymph nodes and to distant sites that shows up on the scan can be treated by radioactive iodine. For cancers that don’t take up iodine, external beam radiation therapy may help treat the tumor or prevent it from growing back in the neck.

Distant metastases may need to be treated with external beam radiation therapy, targeted therapy, or chemotherapy if they do not respond to radioactive iodine. Another option is taking part in a clinical trial of newer treatments.

Recurrent cancer: The options for treating these cancers that come back after initial treatment are basically the same as they are for recurrent papillary cancer (see above).

Medullary thyroid carcinoma

Most doctors advise that patients diagnosed with medullary thyroid carcinoma (MTC) be tested for other tumors that are typically seen in patients with the MEN 2 syndromes (see “What are the risk factors for thyroid cancer?”), such as pheochromocytoma and parathyroid tumors. Screening for pheochromocytoma is particularly important, since the unknown presence of this tumor can make anesthesia and surgery extremely dangerous. If surgeons and anesthesiologists know about such tumors ahead of time, they can medically pre-treat the patient to make surgery safe.

Stages I and II: Total thyroidectomy is the main treatment for MTC and often cures patients with stage I or stage II MTC. Nearby lymph nodes are usually removed as well (central compartment or modified radical neck dissection). Because the thyroid gland is removed, thyroid hormone therapy is needed after surgery. For MTC, thyroid hormone therapy is meant to provide enough hormone to keep the patient healthy, but it does not reduce the risk that the cancer will come back.

Because MTC cells do not take up radioactive iodine, there is no role for radioactive iodine therapy in treating MTC. Still, some doctors give a dose of radioactive iodine to destroy any remaining normal thyroid tissue. If MTC cells are in or near the thyroid, this may affect them as well.

Stages III and IV: Surgery is the same as for stages I and II (usually after screening for MEN 2 syndrome and pheochromocytoma). Thyroid hormone therapy is given afterward. When the tumor is extensive and invades many nearby tissues or cannot be completely removed, external beam radiation therapy may be given after surgery to try to reduce the chance of recurrence in the neck.

For cancers that have spread to distant parts of the body, surgery, radiation therapy, or similar treatments may be used if possible. If these treatments can’t be used, vandetanib (Caprelsa), cabozantinib (Cometriq), or other targeted drugs may be tried. Chemotherapy may be another option. Because these cancers can be hard to treat, another option is taking part in a clinical trial of newer treatments.

Recurrent cancer: If the cancer recurs in the neck or elsewhere, surgery, external radiation therapy, targeted therapy (such as vandetanib or cabozantinib), or chemotherapy may be needed. Clinical trials of new treatments may be another option if standard treatments aren’t effective.

Genetic testing in medullary thyroid cancer: If you are told that you have MTC, even if you are the first one in the family to be diagnosed with this disease, ask your doctor about genetic counseling and testing. Genetic testing can find mutations in the RET gene, which is seen in cases of familial MTC and the MEN 2 syndromes.

If you have one of these mutations, it’s important that close family members (children, brothers, and sisters) be tested as well. Because almost all children and adults with mutations in this gene will develop MTC at some time, most doctors agree anyone who has a RET gene mutation should have their thyroid removed to prevent MTC soon after getting the test results. This includes children, since some hereditary forms of MTC affect children and pre-teens. Total thyroidectomy can prevent this cancer in people with RET mutations who have not yet developed it. Of course, this means that lifelong thyroid hormone replacement will be needed.

Anaplastic carcinoma

Surgery might or might not be used to treat this cancer, because it is often already widespread when it is diagnosed. If the cancer is confined to the area around the thyroid, which is rare, the entire thyroid and nearby lymph nodes may be removed. The goal of surgery is to remove as much cancer in the neck area as possible, ideally leaving no cancer tissue behind. Because of the way anaplastic carcinoma spreads, this is often difficult or not possible.

External beam radiation therapy may be used alone or combined with chemotherapy:

• To try to shrink the cancer before surgery to increase the chance of complete tumor removal
• After surgery to try to control any disease that remains in the neck
• When the tumor is too large or widespread to be treated by surgery

If the cancer is causing (or may eventually cause) trouble breathing, a hole may be placed surgically in the front of the neck and into the windpipe to bypass the tumor and allow the patient to breathe more comfortably. This hole is called a tracheostomy.

For cancers that have spread to distant sites, chemotherapy may be used, sometimes along with radiation therapy if the cancer is not too widespread. Because these cancers can be hard to treat, clinical trials of newer treatments are an option as well.