Papillary thyroid carcinoma is the most common malignant neoplasm of the thyroid gland.
Most patients merely present with a palpable mass in the anterior region of the neck. Usually, no other symptoms are reported. Occasionally, patients may claim difficulties to breath or swallow. Cough may be observed.
Although PTC are malignant tumors, they are most frequently rather slow growing. Thus, if symptoms are present, they are rarely of sudden onset. Rapid increases in tumor volume and additional symptoms such as pain point at differential diagnoses.
Of note, symptoms caused by regional and distant metastases may predominate in some cases. They largely depend on the precise localization of the secondary tumor.
- Cervical Lymphadenopathy
The most frequent presentation of papillary thyroid cancer is a palpable thyroid nodule, cervical lymphadenopathy, or incidental detection on imaging. Locally advanced disease can present with hoarseness or voice alteration. [mdedge.com]
Palpable cervical lymphadenopathy. Insidious or persistent pain lasting for several weeks. Investigations TFTs should be performed for any patient with a thyroid nodule. [patient.info]
[…] evidence shows screening would improve patient outcomes. 2 Initial Laboratory Testing It is important to measure the serum thyrotropin (TSH) level in patients with a nodule >1 cm or who have clinical symptoms or lymphadenopathy. [endocrinologyadvisor.com]
There was no cervical lymphadenopathy. Flexible endoscopy revealed mobile true vocal folds bilaterally. Laboratory studies revealed a normal CBC, Chem-7, and LFTs. Her TSH, T3, fT4 were normal as well. [web.archive.org]
Here we report a 53-year-old man with diffuse goiter and cervical lymphadenopathy who developed symptoms of elevated intracranial pressure. [jjco.oxfordjournals.org]
Entire Body System
- Thyroid Nodule
Thyroid nodules in the context of an autoimmune thyroiditis may have a higher risk of malignancy . [mdedge.com]
[…] of women have a palpable thyroid nodule. [endocrinologyadvisor.com]
Similarly, in HL patients with suspicious thyroid nodule, ultrasound-guided fine needle aspiration of thyroid nodule should be performed to exclude thyroid malignancy. [ncbi.nlm.nih.gov]
Presentation Thyroid cancer presents as a thyroid nodule. Thyroid nodules are frequent (4-50% depending on the diagnostic procedures and the patient's age); however, thyroid cancer is rare (c. 5% of all thyroid nodules). [patient.info]
Keywords: Carcinoma; Papillary; Graves' disease; Hot nodule; Thyroid carcinoma; Thyroid nodule RESUMO A associação de câncer diferenciado da tiróide com nódulo funcionante é muito baixa. [scielo.br]
A 76-year-old female presented with a painful and enlarging mandibular mass. She had been treated in the past for the follicular variant of papillary thyroid carcinoma. A palliative hemi-mandibulectomy was performed. [ncbi.nlm.nih.gov]
Cancerous thyroid lumps aren’t usually painful. But you should get any lump (whether it is painful or not) checked out by your doctor. [cancerresearchuk.org]
Other potential thyroid symptoms include pain at the base of the neck or throat and swelling or a lump under the Adam’s apple area. Any pain or swelling is reason to seek medical advice right away. [livestrong.com]
We ask about general symptoms (anxious mood, depressed mood, fatigue, pain, and stress) regardless of condition. Last updated: January 31, 2019 [patientslikeme.com]
The purpose of this study was to evaluate the rate of papillary thyroid cancer (PTC) in patients thyroidectomized for benign multinodular goiter. [ncbi.nlm.nih.gov]
Moreover, nodular goiter has shown the potential for malignancy and may be a risk factor for the development of TC [ 23 - 25 ] .Therefore, we had also recruited a group of nodular goiter as the disease controls and examined whether nodular goiter may [jcancer.org]
Early iodide ingestion may decrease the formation of goiter. Colloid goiter is a forerunner of nodular goiter. There is a heterogeneity in both iodination and response to TSH. [web.archive.org]
[…] with a concordant diagnosis of a benign nodule rendered by all 24 pathologists. [doi.org]
Consensus diagnostic criteria for EFVPTC were developed by 24 thyroid pathologists. [ncbi.nlm.nih.gov]
For this reason, reliably staging a follicular thyroid cancer is more difficult because it is influenced by the subjective classification made by the pathologist. [web.archive.org]
- Surgical Procedure
Surgical procedure is the major treatment method at present. [ncbi.nlm.nih.gov]
Conservative surgical procedure, such as isthmusectomy and hemithyroidectomy are generally advised for papillary carcinomas that are isolated, well circumscribed, and less than 1.5cm in size, as well as for patients who are relatively young or aged between [docdoc.com.sg]
If unsuccessful, surgical procedures can be done. An infection, if bacterial, can be treated with antibiotics. A brain abscess is drained, and antibiotics are given. NOTE: This is the Consumer Version. [merckmanuals.com]
This information helps the surgeon determine the optimal surgical procedure for the patient. Thyroid cancers can also spread through the bloodstream. [oncolink.org]
Surgical treatment should adhere to the risk-group analysis. Extrathyroidal extension - extra attention to remove all gross tumor during the initial surgical procedure to avoid future recurrences. [shifrinmd.com]
Herein, we are reporting a case of HVPTC in a patient who presented with hemoptysis and an intratracheal blood clot that was aspirated and submitted for cytopathological examination. [ncbi.nlm.nih.gov]
Also, see your doctor if: a lump that has been previously checked suddenly gets bigger you find a lump elsewhere in your neck Hoarse voice A hoarse voice is more likely to be caused by a bacterial or viral infection. [cancerresearchuk.org]
Locally advanced disease can present with hoarseness or voice alteration. [mdedge.com]
[…] time of reporting) 7 67/M Neck mass Yes Skull 131 I Dead of tumor 8 (2 cases) 67/M Neck mass Yes Rib and lung 131 I Alive with disease 79/M Neck mass Yes None CR + 131 I Alive with disease 12 47/M Headache No None CR + 131 I Alive with disease 6 52/F Hoarseness [jjco.oxfordjournals.org]
Percussion There is no retrosternal extension of the lump Auscultation There is no bruit heard Hoarseness of voice present 19. [slideshare.net]
An 11-year-old boy with autism spectrum disorder and moderate intellectual impairment presented with dyspnea on exertion with thyroid carcinoma and diffuses lung metastases. [ncbi.nlm.nih.gov]
She had no fever, arthralgia or arthritis, cough, dyspnea, rash, difficulty with swallowing, paresthesias, abdominal pain, or other symptoms. [casesjournal.biomedcentral.com]
The following are common sign and symptoms associated with anemia: fatigue, headache, dyspnea on exertion, pallor (skin, conjunctiva, nail beds), palpitations, weakness, and sometimes angina in older individuals or those with underlying coronary artery [cancertherapyadvisor.com]
Our patient had no complications and only short-term dysphagia that resolved after temporary diet alteration. [ncbi.nlm.nih.gov]
Patients usually present with a rapidly growing mass in the neck, which may cause symptoms of obstruction such as dyspnoea and dysphagia. [patient.info]
[…] cancer/thyroid cancer syndrome in a first-degree relative, a personal history of thyroid cancer, or prior positive nodules on [18F]fluorodeoxyglucose positron emission tomography (18FDG-PET). 1,2 Physical findings suggestive of malignancy include pain, dysphagia [endocrinologyadvisor.com]
Acute (0 to 6 months) EBRT side effects include esophagitis, dysphagia, erythema, and a need for tracheostomy, while late complications (6 months to 2 years) include xerostomia, esophageal stenosis, tracheal constriction, carotid stenosis, and brachial [thyroid.org]
- Heart Disease
Ginger Hultin | updated on July 6, 2018 Studies estimate that disease of the thyroid gland is more common than diabetes or heart disease and often goes misdiagnosed or undetected. [livestrong.com]
The levels of TSH suppression and optimal thyroid hormone dosing will also depend on the patients age, and associated risk factors for both bone disease and heart disease. [mythyroid.com]
Adverse effects of TSH suppression may include the known consequences of subclinical thyrotoxicosis, including exacerbation of angina in patients with ischemic heart disease, increased risk for atrial fibrillation in older patients ( 272 ), and increased [doi.org]
This phenomenon was experimentally reproduced by direct ligation of the optic nerve, and the use of intracranial balloons to cause increased ICP82 or by induced ocular hypotension.77 The role of central retinal venous pressure in the pathophysiology of [thejns.org]
Side effects include: transient hypertension or hypotension, headache, dizziness, metallic taste, sensation of warmth urge to micturate, nausea (vomiting rare), and abdominal cramps. These side effects are usually mild and transient. [web.archive.org]
- Neck Pain
Over time, you may have one or more lumps (nodules or goiters) in your neck. You may also have any of the following: Difficulty swallowing. Hoarse (rough) voice or trouble talking. Neck pain. Shortness of breath or noisy breathing. [drugs.com]
The below MRI study was obtained for a patient complaining of neck pain following a motor vehicle accident. [endocrineweb.com]
Case Presentation: Y.H. is a 39-year-old female who presented to the Methodist Hospital ER with neck pain, a progressive sensation of choking and tightness in her neck. [web.archive.org]
There are many risk factors for osteoporosis, and many patients with thyroid cancer on suppressive doses of thyroxine have no evidence of osteoporosis. There is no uniformly agreed upon range for TSH and thyroid hormone levels. [mythyroid.com]
[…] effects of TSH suppression may include the known consequences of subclinical thyrotoxicosis, including exacerbation of angina in patients with ischemic heart disease, increased risk for atrial fibrillation in older patients ( 272 ), and increased risk of osteoporosis [doi.org]
Face, Head & Neck
- Neck Mass
X-rays Alive with disease 10 (2 cases) 51/M Neck mass No Lung CR + 131 I Alive with disease 59/M Neck mass Yes None CR + 131 I Alive with disease 11 82/F Neck mass Yes Lung and vertebra CR + 131 I Dead of pneumonia Ref. [jjco.oxfordjournals.org]
Fine needle aspiration biopsy (FNA-b) is an excellent tool for evaluating neoplastic neck masses . Metabolic disease involving the thyroid and parathyroid glands can present as a neck mass. [hindawi.com]
The authors present a case of CMV-PTC in a 10-year-old girl patient without FAP history, who presented with a left neck mass. The patient underwent total thyroidectomy with central compartment neck dissection. [ncbi.nlm.nih.gov]
A thorough anamnesis may reveal childhood exposure to radiation, dietary deficits resulting in iodine deficiency or familial history of endocrine neoplasms. These may indicate an increased individual risk of papillary, follicular or medullary thyroid carcinoma.
Thyroid masses are generally evaluated by histopathological analysis of samples obtained by fine needle aspiration. The latter is best conducted after carrying out a sonographic examination of the thyroid gland. Sonography allows for localization of the pathological mass, for visualization of characteristic cysts and calcifications and this information may help to guide the fine needle aspiration. PTC are well-differentiated neoplasms whose cells are often crowded with large, oval nuclei of pale, ground glass-like appearance. Nucleic indentations convey the impression of cytoplasmatic inclusions.
A similar approach is recommended in case of lymph node alterations. It is not uncommon to detect metastases before the primary tumor. On the other hand, diagnosis of PTC should prompt an extensive revision of regional lymph nodes for possible metastases. Scintigraphy is generally applied to this end. Radiography, magnetic resonance imaging or computed tomography scans are not routinely performed to confirm or stage thyroid cancer. They may, however, be employed as supplemental diagnostic measures.
Staging is important for choosing an adequate therapeutic approach. Staging considers the size of the tumor (T), the presence of metastases in regional lymph nodes (N) and distant tissues (M). In case of PTC, it also depends on the patient's age:
- Patients aged less than 45 years are always considered stage I unless distant metastases are detected, which would lead to their tumor being classified as stage II.
- In patients older than 45 years, stage I corresponds to a tumor that measures < 2 cm in diameter and no metastases. Larger tumors, i.e., those that measure up to 4 cm in diameter, are classified stage II if no metastases are present. Very large tumors (> 4 cm in diameter) or those that metastasized to regional lymph nodes correspond to stage III. The presence of distant metastases indicates stage IV.
Surgical resection of degenerated tissue, subsequent radiation therapy and replacement of thyroid hormones by administrating the respective drugs are the mainstays of PTC therapy.
The following schemes are recommended according to tumor staging:
- Stage I and stage II. If possible, a hemithyroidectomy should be preferred over a near-total or total thyroidectomy. The former is associated with less severe complications for lack of thyroid hormones, but also bears a greater risk of recurrence and should therefore be performed only if the neoplasm is well-delimited to one thyroid lobe. The parathyroid glands should be spared. Removal of lymph nodes may be necessary. Post-operative radioactive iodine therapy decreases the probability of relapses. Life-long substitution of thyroid hormones is usually required. Doses should be adjusted to the individual case and results of blood sample analyses.
- Stage III. These tumors require total thyroidectomy and neck dissection in order to resect affected lymph nodes. Post-operative radioactive iodine therapy should be applied if the tumor has not lost radioiodine avidity. Otherwise, external radiation therapy is indicated. Hormonal therapy should be carried out as described for stages I and II. If parathyroid glands had to be removed in order to completely resect the neoplasm, calcium and vitamin D should be supplemented.
- Stage IV. Treatment largely corresponds to the approach described for stage III. Additional surgical interventions are necessary to resect distant metastases.
The overall prognosis is good. However, it largely depends on tumor stage and age of the patient upon diagnosis. Involvement of lymph nodes, peripheric metastases and old age are unfavorable prognostic factors. Females tend to have a better outcome than males.
PTC are strongly related to irradiation and history provides scary yet impressive examples that underscore this fact. Very high incidence rates have been detected among survivors of the atomic bombing of Hiroshima and Nagasaki in 1945. Studies have shown that the individual risk of thyroid cancer increases with lower ages at the time of exposure . Because tumor development after irradiation is a long-term consequence of this event - latency periods of 30 years have been estimated -, such studies could not yet be conducted with children who lived close to where the Chernobyl nuclear accident happened in 1986. Unfortunately, similarly high incidence rates of PTC have to be expected.
While today, patients who undergo radiographic examinations are usually provided a thyroid collar, head and neck irradiation was a applied as a common therapeutic measure before associated risks were known. In this context, infectious diseases, acne and even aesthetic flaws have been treated with radiation therapy during large parts of the 20th century. These patients may have an increased risk for PTC, but their individual condition will largely depend on the radiation dose they received and on their age during treatment.
If irradiation is used today, either because images of the head and neck region are required for diagnostic purposes or because pathological conditions indicate radiation therapy, the thyroid gland is protected as far as possible. However, some types of cancer require head and neck irradiation and particularly pediatric patients who receive such treatment may have an increased risk of developing PTC. An average exposure to irradiation due to occasional radiographies has not been proven to increase the individual risk for PTC. Nevertheless, any form diagnostic and therapeutic irradiation should always be justified.
In rare cases, gene mutations may account for familial accumulation of PTC cases .
Iodine deficiencies are typically associated with follicular thyroid carcinoma while genetic disorders usually account for medullary thyroid carcinoma .
Incidence rates for PTC among the above mentioned risk groups, i.e., atomic bomb and Chernobyl survivors as well as those people who received considerable head and neck irradiation, may be as high as 10%. And even though the overall incidence of thyroid cancer is much lower, it is still considered a frequent type of cancer. Annually, about 15 per 100,000 women are diagnosed with thyroid cancer, while three times less men are affected. For as of yet unknown reasons, incidence rates have been increasing over the last decades . Improved diagnostic techniques may at least partially explain this apparent trend.
Chromosomal rearrangements affecting the RET (rearranged during transfection) proto-oncogene have been related to PTC . The gene encodes for a receptor tyrosine kinase and gain-of-function mutations presumably contribute to tumor development. Here, constitutive activation of the kinase is triggered by juxtaposition to distinct DNA sequences that are designated papillary thyroid carcinoma (PTC) proteins.
A mutation of the gene encoding for MET receptor tyrosine kinase, a growth factor receptor, has been detected in many cases of thyroid cancer, but an association between gene mutation and tumor characteristics could not yet be established . Different growth factors, e.g., EGF, IGF-1 and TGFβ, have been suggested to play a role in PTC pathogenesis. And although neither of these growth factors binds to the aforementioned MET receptor tyrosine kinase, their pro-oncogenic characteristics make this hypothesis plausible.
Another proto-oncogene frequently mutated in PTC is BRAF, encoding for serine/threonine protein kinase B-Raf. B-RAf is involved in intracellular MAPK signaling and may affect cell growth, proliferation, differentiation and apoptosis. Indeed, the incidence of BRAF mutations seems to have increased simultaneously with PTC incidence rates and has been proposed as a potential explanation for the latter .
A plethora of other mutations has been related to PTC. There seem to be clear differences in mutation patterns encountered in patients who developed PTC after receiving high doses of radiation and those who present with sporadic tumors and without a history of irradiation .
Other than avoiding irradiation whenever possible, no preventive measures can be recommended.
Thyroid cancer refers to any malignant neoplasm of the thyroid gland. In this context papillary, follicular and medullary carcinoma are distinguished. The papillary thyroid carcinoma (PTC) type accounts for two out of three cases of thyroid cancer and is thus the most common form of this disease. There's a strong correlation between exposure to radiation and the individual risk of PTC.
The name of this tumor derives from its papilla-like outgrowths that are, however, not necessarily present at the time of diagnosis. PC may develop as solitary or multiple tumors. They are solid or may include cysts and/or calcifications. Usually, they are hardened, off-white and well-delimited against unaltered thyroid tissue. However, some PC grow infiltratively and their macroscopic appearance does not allow an unmistaken differentiation from other forms of thyroid cancer. Histopathological analyses are required to this end and tissue samples are either obtained by fine-needle aspiration or standard biopsy. PC are well-differentiated and its cells are further characterized by overlapping, oval, ground glass nuclei. Nuclear grooves are commonly found. Of note, mixed forms of papillary and follicular thyroid carcinoma have been described and should be taken into account when analyzing resected tissue . PTC are likely to metastasize via lymphatic vessels and secondary tumors are frequently detected in regional lymph nodes. Hematogenous metastases are less likely. Surgical resection is the therapy of choice and should include all affected lymph nodes to avoid relapses . Post-operative radioactive iodine therapy may be employed to destroy any residual neoplastic tissue.
Papillary thyroid carcinoma (PTC) is the most common type of malignant tumor that develops within the thyroid gland.
There is a strong correlation between irradiation, especially exposure to high radiation doses during childhood, and the individual risk for PTC. In this context, those that survived the atomic bombing of Japan in 1945 or the nuclear accident in Chernobyl in 1986 have very high risks of thyroid cancer. Another risk factor is head and neck irradiation, which has been applied without reservation to treat infectious diseases, acne and even aesthetic flaws until about 1960.
An average exposure to irradiation due to occasional radiographies does not increase the individual risk for PTC.
Most patients present with a painless, slowly-growing mass in their anterior neck region. Possibly, no other symptoms are experienced. Some patients report problems to swallow or breath or claim persistent cough.
An ultrasonographic examination allows the physician to localize the tumor and to assess its extension. It is also useful to guide tissue sampling, which will be done afterwards by aspirating tumor cells with a fine needle. These cells are histopathologically analyzed. Typical features allow for the diagnosis of PTC.
Because PTC tend to spread to regional lymph nodes, these have to be revised for possible metastases. This is usually done with scintigraphy.
PTC require surgical removal. In mild cases, parts of the thyroid gland may be preserved. This is worth striving for since the lack of thyroid hormones after surgery is less severe if these are still produced endogenously. However, partial resection of the thyroid gland is associated with a higher risk of recurrence. Thus, the decision for a partial or total thyroidectomy is based on the characteristics of the individual case.
After surgery, patients are treated with radioactive iodine. It is absorbed by possible remaining cancerous tissue. Thus, at this specific site, a high dose of irradiation is achieved. This treatment destroys residual cancer cells and therefore decreases the risk of recurrence.
In some cases, PTC have lost their avidity for iodine. Such tumors require external radiation therapy after surgery.
Thyroid hormones have to be substituted after thyroidectomy. Patients usually take one dose daily for the rest of their lives.
- Wreesmann VB, Ghossein RA, Hezel M, et al. Follicular variant of papillary thyroid carcinoma: genome-wide appraisal of a controversial entity. Genes Chromosomes Cancer. 2004; 40(4):355-364.
- Clayman GL, Shellenberger TD, Ginsberg LE, et al. Approach and safety of comprehensive central compartment dissection in patients with recurrent papillary thyroid carcinoma. Head Neck. 2009; 31(9):1152-1163.
- Imaizumi M, Ohishi W, Nakashima E, et al. Association of radiation dose with prevalence of thyroid nodules among atomic bomb survivors exposed in childhood (2007-2011). JAMA Intern Med. 2015; 175(2):228-236.
- Musholt TJ, Musholt PB, Petrich T, Oetting G, Knapp WH, Klempnauer J. Familial papillary thyroid carcinoma: genetics, criteria for diagnosis, clinical features, and surgical treatment. World J Surg. 2000; 24(11):1409-1417.
- Monson JP. The epidemiology of endocrine tumours. Endocr Relat Cancer. 2000; 7(1):29-36.
- Davies L, Welch HG. Current thyroid cancer trends in the United States. JAMA Otolaryngol Head Neck Surg. 2014; 140(4):317-322.
- Romei C, Ciampi R, Elisei R. A comprehensive overview of the role of the RET proto-oncogene in thyroid carcinoma. Nat Rev Endocrinol. 2016; 12(4):192-202.
- Wasenius VM, Hemmer S, Karjalainen-Lindsberg ML, Nupponen NN, Franssila K, Joensuu H. MET receptor tyrosine kinase sequence alterations in differentiated thyroid carcinoma. Am J Surg Pathol. 2005; 29(4):544-549.
- Mathur A, Moses W, Rahbari R, et al. Higher rate of BRAF mutation in papillary thyroid cancer over time: a single-institution study. Cancer. 2011; 117(19):4390-4395.
- Port M, Boltze C, Wang Y, Roper B, Meineke V, Abend M. A radiation-induced gene signature distinguishes post-Chernobyl from sporadic papillary thyroid cancers. Radiat Res. 2007; 168(6):639-649.