Thyroid Cancer

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Adam Hooten & Andrew Stethen from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Adam Hooten, Andrew Stethen, Lucinda hampton, Kim Jackson, Vidya Acharya, WikiSysop, Elaine Lonnemann, 127.0.0.1, Wendy Walker and Adam Vallely Farrell  

Definition/Description

The thyroid gland regulates hormones in the body that control heart rate, blood pressure, weight, and body temperature. Thyroid cancer forms in the thyroid gland and is broken down into four main types: papillary, follicular, medullary, and anaplastic. Papillary thyroid cancer is the most common type and grows slowly in the follicular cells. Follicular thyroid cancer is slightly less common but also grows slowly in the follicular cells. Both forms look similar to normal thyroid tissue under a microscope and account for over 90% of all thyroid cancers. These two forms are often curable when found under the age of 45. Medullary thyroid cancer develops in the C cells and is sometimes the result of a genetic syndrome. This cancer does not resemble normal thyroid tissue and accounts for almost 5% of thyroid cancers. This type can be controlled if it is diagnosed before metastasis. The anaplastic form of thyroid cancer is the least common at 2%, but it is fast growing and harder to treat.

Prevalence

Estimated new cases in the United States in 2014: 62,980 (47,790 in women and 15,190 in men).

Estimated deaths in the United States in 2014: 1,890 (1,060 women and 830 men).

Thyroid cancer is more commonly diagnosed at a younger age than most other adult cancers. Nearly 70% of new cases are found in people younger than 55 and about 2% are found in children and teens. Thyroid cancer diagnoses have increased in the recent years and is the most rapidly increasing cancer in the United States. This increase can mostly be attributed to the advances in the thyroid ultrasound which can detect very small thyroid nodules. The death rate for thyroid cancer remains low compared to other cancers. 3

Characteristics/Clinical Presentation

Generally, Thyroid cancer does not cause any symptoms, but a person may have a lump or nodule around the thyroid in the neck area.4 The most common sign of thyroid cancer is a nodule that may be noticed by a physician, or even the patient themselves as they put on a necklace, button a shirt or coat, or looking in the mirror. 4 On rare occasions, thyroid cancer may actually present with symptoms such as pain in the jaw, neck or ear areas. The nodule can compress the airway if it gets large enough wich can lead to difficulty breathing or swallowing and hoarsness. The patient may complain of a "tickle in the throat". 4 

Associated Co-morbidities

An associated co-morbidity is a disorder or disease that predisposes a person to develop thyroid cancer.

• Several inherited conditions have been linked to different types of thyroid cancer, including family history. However, most people who develop thyroid cancer do not have an inherited  condition or a family history of the disease.

• Medullary thyroid cancer
  
• About 1 out of 3 medullary thyroid carcinomas (MTCs) result from inheriting an abnormal gene. These cases are known as familial medullary thyroid carcinoma (FMTC).
• The combination of FMTC and tumors of other endocrine glands is called multiple endocrine neoplasia type 2 (MEN 2). There are 2 subtypes, MEN 2a and MEN 2b, both of which are caused by mutations in a gene called RET.
•  In MEN 2a, MTC occurs along with pheochromocytomas (tumors that make adrenaline) and with parathyroid gland tumors.
•  In MEN 2b, MTC is associated with pheochromocytomas and with benign growths of nerve tissue on the tongue and elsewhere called neuromas. This subtype is much less common than MEN 2a.
• In the above inherited forms of MTC, the cancers often develop during childhood or early adulthood and can spread early. MTC is most aggressive in the MEN 2b syndrome. If MEN 2a, MEN 2b, or isolated FMTC runs in your family, you may be at very high risk of developing MTC.  10
  

• Other thyroid cancers
• Familial adenomatous polyposis (FAP): Persons with this disorder are at an increased risk for papillary thyroid cancer
• Cowden disease: Can cause an increased risk of thyroid problems and papillary or follicular thyroid cancers
• Carney complex, type I: Can cause an increased risk of papillary or follicular thyroid cancers.
• Familial nonmedullary thyroid carcinoma: Thyroid cancer occurs more often in some families, and is often seen at an earlier age. The most common form of thyroid cancer that runs in these families is the papillary type. Genes on chromosome 19 and chromosome 1 are suspected of causing these familial cancers.
• Family history: Having a first-degree relative (parent or sibling) with thyroid cancer, even without a known inherited syndrome in the family, increases your risk of thyroid cancer. The genetic basis for these cancers is not totally clear.10

Medications

Below is a list of cancer drugs that are approved by the Food and Drug Administration (FDA) for thyroid cancer. 3

Adriamycin PFS (Doxorubicin Hydrochloride)
Adriamycin RDF (Doxorubicin Hydrochloride)
Cabozantinib-S-Malate
Caprelsa (Vandetanib)
Cometriq (Cabozantinib-S-Malate)
Doxorubicin Hydrochloride
Nexavar (Sorafenib Tosylate)
Sorafenib Tosylate
Vandetanib

Diagnostic Tests/Lab Tests/Lab Values

Thyroid cancer is commonly diagnosed using a fine needle aspiration biopsy of a thyroid nodule. The biopsy can also be done after the nodule has been removed during surgery. 4 Thyroid lab test are generally not helpful in the diagnosis of thyroid cancer, the lab tests are usually normal regardless if a cancer is present. 4 

Etiology/Causes

The cause of thyroid cancer is unknown, however, people who have their thyroid gland exposed to high doses of radiation or have a family history of thyroid cancer are at a higher risk of developing thyroid cancer. The risk of thyroid cancer also increases as we age.4 High doses of radiation such as from reoccuring chest x-rays, especially in childhood, can lead to thyroid cancer. 4 Treatments and x-rays for Hodgkin'd disease and breast cancer have been shown to have a greater risk for thyroid cancer.4 Generally, exposure form routine x-rays such as a simple chest x-ray and dental x-rays have not been linked to increaseing the risk for thyroid cancer. 4 Radioactive iodine has also been linked to causing thyroid cancer. Examples of radioactive iodine causing thyroid cancer would include Chernobyl, a Russian nuclear power plant accident in 1986 and the tsunami related nuclear power plant disaster in 2011 in Japan. 4

Systemic Involvement

The most common places in the body for thyroid cancer to spread to are the lungs, liver, and bones. 6

Lungs: Patients with cancer that has spread to the lungs may not have any associated signs and symptoms. Possible symptoms could include the following though: 7

• coughing up blood
• chest pain
• shortness of breath
• weakness
• weight loss

Liver:  In the early stages there may not be any signs or symptoms. In the later stages, the liver begins to swell and can cause the following symptoms: 8

• loss of appetite
• weight loss
• jaundice
• nausea
• confusion
• sweats/fever
• pain in right shoulder or right upper abdomen

Bone: 9

• Bone pain is often the first symptom. Pain is worse at night and is better with movement.
• Broken bones
• Numbness or paralysis
• Loss of appetite, confusion, nausea

Medical Management (current best evidence)

There are various types of treatment options available for those diagnosed with thyroid cancer. There are standard treatments and some that are being tested in clinical trials. There are currently five standard treatments:

1. Surgery- most common form of treatment

• Lobectomy (Removal of the lobe of the lung with the cancer)
• Near-toal thyroidectomy (Removal of nearly all the thyroid gland)
• Total thyroidectomy (Removal of all the thyroid gland)
• Lymphadenectomy (Removal of cancerous lymph nodes in the neck)

2. Radiation therapy (including radioactive iodine therapy or RAI)

• RAI is used for follicular and papillary thyroid cancers. This is taken by mouth and will collect any remaining thyroid cancer cells that may have spread. Since only the thyroid gland takes up iodine, no other tissue is harmed.
• Radiation uses high energy x-rays to kill cancer cells and keep them from growing (depends on stage and type of cancer).

3. Chemotherapy

• Uses drugs (by mouth or injection) to stop the growth of cancer cells. (Depends on type and stage of cancer).

4. Thyroid hormone therapy

• Hormone therapy removes hormones or blocks their action to stop cancer cells from growing. For thyroid cancer, drugs are given to prevent the body from making Thyroid-stimulating hormone (TSH) because this hormone increases the chance that the thyroid cancer will grow or recur.

5. Targeted therapy

• Uses drugs or other substances to kill cancerous cells and avoid harming normal cells. Vandetanib, a type of Tyrosine Kinase Inhibitor (TKI), is used to block signals needed for thyroid tumors to grow. 5

Patients with thyroid cancer may want to think about participating in a clinical trial. More information can be found at: http://www.cancer.gov/clinicaltrials

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

11

Differential Diagnosis

Below are several differential diagnosis of thyroid cancer: 5

Goiter

Hashimoto's Thyroiditis

Benign Thyroid nodules or cysts

Graves Disease

Thyroid Lymphoma

Subacute Thyroiditis

Hyperthyroidism

Hypothyroidism

Multiple Endocrine Neoplasia Type 2

Case Reports/ Case Studies

Bouillet B, Petit J, Tison L, Beynat C, Brunot S, Baudoin N. The first case report of diaphragmatic paralysis as a paraneoplastic syndrome of medullary thyroid carcinoma. Clinical Endocrinology [serial online]. July 2011;75(1):143-145. Click Here for article.
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=d38d7d1d-dbe5-4011-9075-51fbe4b4cb0c%40sessionmgr4004&vid=9&hid=4111

Goatman C, Goldsmith P, Antonopoulos V, Ali B. Metastasis of Colorectal Adenocarcinoma to the Thyroid: A Case Report and Review of the Literature. Case Reports In Surgery [serial online]. January 2012;:1-3.
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=d38d7d1d-dbe5-4011-9075-51fbe4b4cb0c%40sessionmgr4004&vid=11&hid=4111

Kainuma K, Kitoh R, Yoshimura H, Usami S. The first report of bilateral retropharyngeal lymph node metastasis from papillary thyroid carcinoma and review of the literature. Acta Oto-Laryngologica [serial online]. December 2011;131(12):1341-1348.
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=d38d7d1d-dbe5-4011-9075-51fbe4b4cb0c%40sessionmgr4004&vid=10&hid=4111

Poggi M, Sorrentino F, Cianciulli P, et al. Malignancies in β-Thalassemia Patients: First Description of Two Cases of Thyroid Cancer and Review of the Literature. Hemoglobin [serial online]. August 2011;35(4):439-446.
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=8&sid=d38d7d1d-dbe5-4011-9075-51fbe4b4cb0c%40sessionmgr4004&hid=4111

 

 add links to case studies here (case studies should be added on new pages using the case study template)

Resources

American Throid Association. http://www.thyroid.org/cancer-of-the-thyroid-gland/

Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/thyroid-cancer/basics/definition/con-20043551

National Cancer Institute. http://www.cancer.gov/cancertopics/types/thyroid

American Society of Clinical Oncology. http://www.cancer.net/cancer-types/thyroid-cancer

Thyroid Cancer Survivors' Association. http://www.thyca.org/

Thyroid Cancer Center. http://www.endocrineweb.com/conditions/thyroid-cancer

American Association of Clinical Endocrinologists. https://www.aace.com/

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.

 

1) National Institutes of Health. Thyroid Cancer. National Cancer Institute.http://www.cancer.gov/cancertopics/types/thyroid. Accessed March 6, 2014.

2) American Society of Clinical Oncology. Thyroid Cancer. Cancer.net. Reviewed 7/2013. http://www.cancer.net/cancer-types/thyroid-cancer. Accessed March 6, 2014.

3)  National Cancer Institute. Thyroid Cancer. Cancer.gov. http://www.cancer.gov/cancertopics/druginfo/thyroidcancer. Accessed March 20, 2014.

4) American Thyroid Association. Thyroid Cancer. Thyroid.org. http://www.thyroid.org/cancer-of-the-thyroid-gland/. Accessed March 20, 2014.

5) http://reference.medscape.com/article/282084-differential

Adam 3) http://www.cancer.org/acs/groups/cid/documents/webcontent/003144-pdf.pdf

Adam 5) http://www.cancer.gov/cancertopics/pdq/treatment/thyroid/Patient/page4

Adam 6) http://www.cancer.gov/cancertopics/factsheet/Sites-Types/metastatic

Adam 7) http://www.healthline.com/health/metastatic-cancer-to-the-lung

Adam 8) http://www.healthline.com/health/liver-metastases

Adam 9) http://www.webmd.com/cancer/features/bone-metastasis-what-happens

Adam 10) http://www.cancer.org/acs/groups/cid/documents/webcontent/003144-pdf.pdf

Adam 11) http://www.cancer.org/cancer/thyroidcancer/detailedguide/thyroid-cancer-treating-cam