Elsevier

Surgical Oncology

Volume 16, Issue 4, December 2007, Pages 237-247
Surgical Oncology

REVIEW
Palliation of advanced thyroid malignancies

https://doi.org/10.1016/j.suronc.2007.08.006Get rights and content

Summary

While most thyroid cancers are slow-growing and have an excellent prognosis after appropriate treatment, a subset of thyroid cancers behave aggressively, and approximately 1500 individuals in the US will die of the disease in the year 2007. Advanced thyroid malignancies can cause distressing and life-threatening symptoms by local invasion in the neck, growth of distant metastases in the lung, bone, and other organs, and tumor production of bioactive substances in the case of medullary thyroid cancer. This article will review palliative modalities, including surgery, radioactive iodine, external beam radiation, and chemotherapy, as well as novel targeted therapies, for the treatment of patients with advanced thyroid malignancies.

Introduction

In the year 2007, an estimated 33,550 new cases of thyroid cancer will be diagnosed in the United States. While the overall 5-year survival for thyroid cancer is excellent (over 96%), approximately 1500 individuals in the US will die of the disease in 2007 [1].

Patients with advanced cancer frequently develop multiple symptoms for a period of weeks to months before death. Common physical symptoms include pain, weakness, fatigue, nausea and vomiting, shortness of breath, and cachexia-anorexia. Neuropsychiatric symptoms include depression, anxiety, insomnia, and delirium [2].

Due to the anatomical location of the thyroid gland, advanced thyroid malignancies frequently impinge upon or invade important structures in the neck such as the trachea, esophagus, major blood vessels, and nerves, causing distressing and life-threatening symptoms such as dyspnea, dysphagia, and hemoptysis. Cancers that metastasize to distant sites such as the lungs, bone, and liver can cause pain and organ dysfunction. As a neuroendocrine tumor, medullary thyroid cancer can also cause symptoms such as diarrhea and flushing secondary to tumor secretion of various bioactive amines and peptides. These symptoms are often a source of great discomfort and distress for the patient with advanced thyroid cancer, as well as his or her family, and represent an important challenge for the treating physician. This article will discuss palliative treatments, including surgery, radioactive iodine (RAI), external beam radiation, and chemotherapy, for a variety of symptoms that arise in patients with advanced thyroid cancer.

Section snippets

Palliative treatment of well-differentiated thyroid cancer

The well-differentiated—i.e., papillary and follicular—thyroid carcinomas (WDTCs) are typically indolent, with excellent long-term survival rates when treated with surgery and RAI [3]. However, a subset of tumors exhibit aggressive behavior. Advanced malignancies with extensive local invasion or distant metastases are often incurable. For these patients, the goal of therapy is to extend life and palliate symptoms.

Palliative treatment of Hürthle cell thyroid cancer

Hürthle cell carcinomas (HCCs), first described in 1928 by Ewing [52], account for approximately 6% of all well-differentiated thyroid cancers [53], and are classified by the World Health Organization as a variant of follicular thyroid cancer [54]. Hürthle cells, also known as oxophylic cells, oncocytic cells, and Askanazy cells, are characterized by abundant granular pink cytoplasm containing many mitochondria. Like FTCs, HCCs are differentiated from adenomas on the basis of capsular or

Palliative treatment of medullary thyroid cancer

Medullary thyroid carcinoma (MTC), which arises from calcitonin-secreting parafollicular cells of the thyroid gland, accounts for 2–5% of all cases of thyroid cancer in the US [70]. The average 5-year survival for MTC (83%) is lower than for papillary and follicular thyroid cancer (90–94%) [71], [72]. The natural history of MTC is significant for early metastasis to local and regional lymph nodes. In advanced cases MTC can invade local structures such as the trachea and jugular vein, and

Palliative treatment of anaplastic thyroid cancer

Anaplastic thyroid carcinoma (ATC) is one of the most lethal malignancies, with a median survival of only 4–12 months from the time of diagnosis [111]. Patients typically present with a rapidly enlarging neck mass, and symptoms related to mechanical compression, such as dyspnea, stridor, dysphagia, hoarseness, and pain, are common. Distant metastases are evident in half of patients at presentation, and another 25% develop metastases during the course of the illness. As with WDTC, the lung is

Palliative treatment thyroid lymphoma

Primary thyroid lymphoma (PTL) is an uncommon malignancy. It accounts for less than 4% of all extra-nodal non-Hodgkin's lymphomas and 5% of thyroid malignancies [143], [144]. PTLs typically occur in middle-to older-aged women and frequently arise in the setting of autoimmune thyroiditis [145].

As in ATC, the most common symptom in PTL is a rapidly enlarging neck mass. Symptoms of airway or esophageal obstruction develop in 30% of patients [146]. These symptoms, including dyspnea, dysphagia,

Conclusions

The majority of thyroid cancers are slow growing and have an excellent prognosis after surgical and medical therapy. However, a subset of thyroid cancers do not follow an indolent course, and exhibit aggressive behavior. Advanced thyroid malignancies can cause distressing and life-threatening symptoms by local invasion, growth of distant metastases, and tumor production of hormones. A variety of treatments are available for the palliative care of patients with incurable thyroid cancer. Novel

References (154)

  • H.R. Tollefsen et al.

    Hurthle cell carcinoma of the thyroid

    American Journal of Surgery

    (1975)
  • R.G. Watson et al.

    Invasive hurthle cell carcinoma of the thyroid: natural history and management

    Mayo Clinic Proceedings

    (1984)
  • M.K. McLeod et al.

    Hurthle cell neoplasms of the thyroid

    Otolaryngologic Clinics of North America

    (1990)
  • N. Bhattacharyya

    A population-based analysis of survival factors in differentiated and medullary thyroid carcinoma

    Otolaryngology-Head and Neck Surgery

    (2003)
  • N. Massoll et al.

    Diagnosis and management of medullary thyroid carcinoma

    Clinical and Laboratory Medicine

    (2004)
  • D. Giuffrida et al.

    Current diagnosis and management of medullary thyroid carcinoma

    Annals of Oncology

    (1998)
  • L.M. Brunt et al.

    Advances in the diagnosis and treatment of medullary thyroid carcinoma

    Surgical Clinics of North America

    (1987)
  • K. Lorenz et al.

    Selective arterial chemoembolization for hepatic metastases from medullary thyroid carcinoma

    Surgery

    (2005)
  • J.L. Pasieka et al.

    The palliative role of 131I-MIBG and 111In-octreotide therapy in patients with metastatic progressive neuroendocrine neoplasms

    Surgery

    (2004)
  • American Cancer Society. What are the key statistics about thyroid cancer? Available at:...
  • R. Udelsman et al.

    The current management of thyroid cancer

    Advances in Surgery

    (1999)
  • G.P. Breaux et al.

    Treatment of locally invasive carcinoma of the thyroid: How radical?

    American Journal of Surgery

    (1980)
  • W.M. Silliphant et al.

    Thyroid carcinoma and death. A clinicopathological study of 193 autopsies

    Cancer

    (1964)
  • M. Friedman et al.

    Treatment of patients with carcinoma of the thyroid invading the airway

    Archives of Otolaryngology-Head & Neck Surgery

    (1994)
  • E. Britto et al.

    Laryngotracheal invasion by well-differentiated thyroid cancer: diagnosis and management

    Journal of Surgical Oncology

    (1990)
  • T.V. McCaffrey et al.

    Locally invasive papillary thyroid carcinoma: 1940–1990

    Head and Neck

    (1994)
  • S.W. Bayles et al.

    Management of thyroid carcinoma invading the aerodigestive tract

    Laryngoscope

    (1998)
  • L.P. Kowalski et al.

    Results of the treatment of locally invasive thyroid carcinoma

    Head and Neck

    (2002)
  • T.S. Reeve et al.

    Secondary thyroidectomy: a twenty-year experience

    World Journal of Surgery

    (1988)
  • T.C. Chao et al.

    Reoperative thyroid surgery

    World Journal of Surgery

    (1997)
  • D.B. Wilson et al.

    Thyroid reoperations: indications and risks

    American Journal of Surgery

    (1998)
  • C. Sturgeon et al.

    Identification and treatment of aggressive thyroid cancers. Part 2: risk assessment and treatment

    Oncology (Williston Park)

    (2006)
  • N.A. Samaan et al.

    Impact of therapy for differentiated carcinoma of the thyroid: an analysis of 706 cases

    Journal of Clinical Endocrinology and Metabolism

    (1983)
  • A.P. Brown et al.

    Radioiodine treatment of metastatic thyroid carcinoma: the royal marsden hospital experience

    British Journal of Radiology

    (1984)
  • J.P. Massin et al.

    Pulmonary metastases in differentiated thyroid carcinoma. study of 58 cases with implications for the primary tumor treatment

    Cancer

    (1984)
  • M. Schlumberger et al.

    Long-term results of treatment of 283 patients with lung and bone metastases from differentiated thyroid carcinoma

    Journal of Clinical Endocrinology and Metabolism

    (1986)
  • J.J. Ruegemer et al.

    Distant metastases in differentiated thyroid carcinoma: a multivariate analysis of prognostic variables

    Journal of Clinical Endocrinology and Metabolism

    (1988)
  • J. Hoie et al.

    Distant metastases in papillary thyroid cancer. A review of 91 patients

    Cancer

    (1988)
  • A.F. Leger

    Distant metastasis of differentiated thyroid cancers. Diagnosis by 131 iodine (I 131) and treatment

    Annals of Endocrinology (Paris)

    (1995)
  • A.R. Shaha et al.

    Differentiated thyroid cancer presenting initially with distant metastasis

    American Journal of Surgery

    (1997)
  • J.K. Harness et al.

    Deaths due to differentiated thyroid cancer: a 46-year perspective

    World Journal of Surgery

    (1988)
  • B. Niederle et al.

    Surgical treatment of distant metastases in differentiated thyroid cancer: indication and results

    Surgery

    (1986)
  • D. Casara et al.

    Different features of pulmonary metastases in differentiated thyroid cancer: natural history and multivariate statistical analysis of prognostic variables

    Journal of Nuclear Medicine

    (1993)
  • S.F. Dinneen et al.

    Distant metastases in papillary thyroid carcinoma: 100 cases observed at one institution during 5 decades

    Journal of Clinical Endocrinology and Metabolism

    (1995)
  • M. Schlumberger et al.

    Radioactive iodine treatment and external radiotherapy for lung and bone metastases from thyroid carcinoma

    Journal of Nuclear Medicine

    (1996)
  • F. Pacini et al.

    Therapeutic doses of iodine-131 reveal undiagnosed metastases in thyroid cancer patients with detectable serum thyroglobulin levels

    Journal of Nuclear Medicine

    (1987)
  • M. Schlumberger et al.

    Detection and treatment of lung metastases of differentiated thyroid carcinoma in patients with normal chest X-rays

    Journal of Nuclear Medicine

    (1988)
  • J.D. Pineda et al.

    Iodine-131 therapy for thyroid cancer patients with elevated thyroglobulin and negative diagnostic scan

    Journal of Clinical Endocrinology and Metabolism

    (1995)
  • D. Casara et al.

    Distant metastases in differentiated thyroid cancer: long-term results of radioiodine treatment and statistical analysis of prognostic factors in 214 patients

    Tumori

    (1991)
  • C.A. Proye et al.

    Is it still worthwhile to treat bone metastases from differentiated thyroid carcinoma with radioactive iodine?

    World Journal of Surgery

    (1992)
  • Cited by (0)

    View full text