Thyroid cancer is generally noticed as a painless, distinct, solitary nodule in the thyroid region (lower) of the throat externally. Solitary nodules have a much higher chance of turning out to be malignant in older patients beyond 60 years of age or in patients younger than 30 years.

Patients may complain of change in voice or increase in hoarseness. They may also complain of dysphagia due to digestive tract involvement. Growth of nodule is a sign of malignancy.

Thyroid nodules when present in males have higher chances of being malignant. Enlargement of lymph nodes situated in the neck region can also be a sign of malignancy. Patients with family history of thyroid carcinoma must be checked thoroughly.

• Cervical Lymphadenopathy

  He presented to our cancer clinic at the Oncology Centre -Mansoura University with recurrent mass at the right lower parotid region, left cervical lymphadenopathy and left axillary lymphadenopathy. [ncbi.nlm.nih.gov]

  Palpable cervical lymphadenopathy. Insidious or persistent pain lasting for several weeks. Investigations [ 2 ] TFTs should be performed for any patient with a thyroid nodule. [patient.info]

• Thyroid Nodule

  Abstract Differentiation of benign and malignant thyroid nodules is crucial for clinical management. [ncbi.nlm.nih.gov]

  As people age, they are more likely to develop a thyroid nodule. By the time we are 80 years of age, 90% of us will have at least one thyroid nodule. Fewer than 1% of all thyroid nodules are malignant (cancerous). [endocrineweb.com]

  Thyroid nodules are present in up to 50% of the adult population, as determined by ultrasonography, and less than 15% of thyroid nodules are malignant ( 1 - 6 ). [kjronline.org]

  As the thyroid gland is a fairly superficial organ in the neck, a thyroid nodule could be noticed early, at which time medical attention should be sought. Not every thyroid nodule a thyroid cancer. [oncolink.org]

• Pain

  These may include: a large mass in the neck pain in the neck, jaw, or ear choking sensations People with cancer that has spread to the nerves that control the vocal cords may also experience hoarseness or changes in their voice. [medicalnewstoday.com]

  We describe a case of a 64-year-old woman who presented with abdominal pain. On subsequent imaging, she was found to have a colonic mass with metastatic lesions in the lungs and tumour involving left kidney. [ncbi.nlm.nih.gov]

  The below MRI study was obtained for a patient complaining of neck pain following a motor vehicle accident. [endocrineweb.com]

• Goiter

  Chest goiter removal removes goiters (enlarged thyroid) that extend into the chest. Removal of cancer that has spread to other areas of the neck (neck dissections) may be necessary when cancers spread to lymph nodes or organs in the neck. [dukehealth.org]

  goiters don't cause any symptoms at all. [everydayhealth.com]

  Multinodular Goiter A multi-nodular goiter is an enlarged thyroid gland with a goiter comprised of multiple thyroid nodules. [surgery.ucsf.edu]

  Competitive allele-specific Taqman PCR was performed in 147 samples of thyroid tissue DNA obtained from patients histologically diagnosed with papillary thyroid cancer (PTC), colloid goiters, and follicular adenomas. [ncbi.nlm.nih.gov]

  Therefore, patients should ask their relatives for a family history of papillary thyroid cancer, goiter Goiter - enlarged thyroid, colon/rectal tumors, or breast cancer. [endocrinediseases.org]

• Lymphadenopathy

  He presented to our cancer clinic at the Oncology Centre -Mansoura University with recurrent mass at the right lower parotid region, left cervical lymphadenopathy and left axillary lymphadenopathy. [ncbi.nlm.nih.gov]

• Asymptomatic

  The USPSTF focused its current recommendation on the general asymptomatic adult population. [doi.org]

  Most commonly presents as an asymptomatic thyroid nodule detected by palpation or ultrasound in a woman in her 30s or 40s. The most important diagnostic test is fine-needle aspiration. [bestpractice.bmj.com]

  The USPSTF recommends against screening for thyroid cancer in asymptomatic adults. (D recommendation). [ncbi.nlm.nih.gov]

  Patients typically present with an asymptomatic thyroid nodule, although many cases are now diagnosed during routine screening of affected kindreds with MEN 2A or MEN 2B before a palpable tumor develops. [merckmanuals.com]

• Aspiration

  Burman, Variability in Reporting Fine-Needle Aspirations of Thyroid, Thyroid, 20, 1, (109), (2010). [dx.doi.org]

  The most important diagnostic test is fine-needle aspiration. Treatment is usually total thyroidectomy followed by radioactive iodine ablation and TSH suppression (papillary or follicular). [bestpractice.bmj.com]

• Hypertension

  CASE PRESENTATION: An adult male with metastatic medullary thyroid cancer presented with hyperglycemia, hypernatremia, hypokalemia, hypertension, acne-like rash, and diabetes insipidus (urine volume >8 L/d, osmolality 190 mOsm/kg). [ncbi.nlm.nih.gov]

  Pheochromocytomas should be identified and removed before thyroidectomy because of the danger of provoking hypertensive crisis during the operation. [merckmanuals.com]

• Erythema

  […] administration with associated elevation of insulin, C-peptide, and proinsulin levels Vasoactive intestinal peptide 1% [ 7, 20 ] Watery diarrhea Hypokalemia Achlorhydria Glucagonoma 1% [ 7, 20 ] Diabetes mellitus Diarrhea Depression Necrolytic migratory erythema [cancer.gov]

  The orally available anti-angiogenic tyrosine kinase inhibitors (axitinib, motesanib, and sorafenib) have numerous common side effects, including hypertension, diarrhea, fatigue, skin rashes and erythema, and weight loss, and various drug-specific toxicities [dx.doi.org]

• Suggestibility

  Indirect laryngoscopy Hard cervical masses suggest metastases of regional lymph nodes and paralysis of vocal fold suggests recurrent laryngeal nerve involvement. [symptoma.com]

  This suggests that many follicular carcinomas might be initially analyzed as non-malignant lesions. [kjronline.org]

  The lack of radioiodine uptake, both in the bone lesions and shoulder mass, suggested the possibility of less differentiated, non-avid radioiodine lesions, or the absence of any relation between pathologies. [ncbi.nlm.nih.gov]

• Aggressive Behavior

  Presence of multiple oncogenic mutations in the FNA specimen was highly indicative of cancer, and suggestive of a cancer with propensity toward more aggressive biological behavior. [ncbi.nlm.nih.gov]

  Most cancers with RET/PTC rearrangements are WD-PTC, which are usually not associated with aggressive behavior. Accordingly, we found only two recurrent/metastatic RAIR tumors harboring RET/PTC oncogenes. [dx.doi.org]

  This article will focus on the identification and treatment of thyroid cancers of follicular cell origin with more aggressive biologic behavior. [cancernetwork.com]

  Junho LEE, Yumie RHEE, Sihoon LEE, Chul Woo AHN, Bong Soo CHA, Kyung Rae KIM, Hyun Chul LEE, Seung Il KIM, Cheong Soo PARK and Sung-Kil LIM, Frequent, Aggressive Behaviors of Thyroid Microcarcinomas in Korean Patients, Endocrine Journal, 10.1507/endocrj.K06 [doi.org]

• Neck Swelling

  Symptoms vary depending on the type of thyroid cancer, but may include: Cough Difficulty swallowing Enlargement of the thyroid gland Hoarseness or changing voice Neck swelling Thyroid lump (nodule) Your health care provider will perform a physical exam [nlm.nih.gov]

  Talk to your healthcare provider right away if you have any of the following signs and/or symptoms: A lump that you can feel on your neck, sometimes with no other symptoms Neck swelling Voice changes, including increasing hoarseness Trouble breathing [labtestsonline.org]

  It can cause severe signs and symptoms, such as neck swelling that worsens very quickly and may lead to difficulty breathing and swallowing. Medullary thyroid cancer. [mayoclinic.org]

• Irritability

  Sometimes large lumps may cause: Pain in your neck, jaw or ear Difficulty in breathing or swallowing An irritation or ‘tickle in the throat’ A change in your voice Swollen glands in the neck Often, thyroid cancer is discovered by accident when imaging [cancernz.org.nz]

  After radioiodine treatment, some patients experience neck tenderness, nausea and stomach irritation, and dry mouth ( xerostomia ). [encyclopedia.com]

  Hyperplasia can be caused by several factors or conditions, including chronic irritation. Dysplasia is a more serious condition than hyperplasia. In dysplasia, there is also a buildup of extra cells. [cancer.gov]

  Grant is much taken with the theory that many of Adams's quirks and character defects can be attributed to Graves' disease, a thyroid condition that would account for Adam's sore eyes and the bouts of depression, irritability and paranoia that caused [web.archive.org]

The ultimate goal of workup is to differentiate the nodule into malignant or benign. Following are the means of tests used to determine this:

• First and foremost is a thorough examination of the suspected patients which includes: Careful examination of head and neck along with thyroid gland and soft tissue in cervical region.
• Indirect laryngoscopy

Hard cervical masses suggest metastases of regional lymph nodes and paralysis of vocal fold suggests recurrent laryngeal nerve involvement.

Laboratory tests

• FNAC (fine needle aspiration biopsy): This is an important diagnostic test in evaluating thyroid nodules [5]. On basis of the results of this test, we can know if the nodule is benign or malignant. In around 50% of the cases, the test gives definitive diagnosis but in patients whose findings are non-diagnostic, we can repeat the biopsy or tissue diagnosis can be done by undergoing surgery,
• Serum TSH levels: A sensitive TSH assay helps in evaluating solitary thyroid nodules for e.g. low serum TSH levels are suggestive of autonomously functioning nodule.
• Serum calcitonin levels: High levels of serum calcitonin indicates the presence of medullary thyroid carcinoma [6].
• Polymerase chain reaction (PCR) assay for germline mutations in the RET proto-oncogene helps in diagnosing familial medullary thyroid carcinoma [7].

Imaging studies

• Ultrasonography (USG): Neck USG is commonly used in evaluating thyroid diseases, but it is not very useful in differentiating the malignant and benign nodules. Many low risk thyroid cancer cases were diagnosed due to widespread usage of USG [8] [9].
• Thyroid radioiodine imaging: It helps in determining operational status of a nodule but it does not rule out cancer.
• CT scan or MRI scan: Helps in evaluating the neck region completely for any mass or metastatic lymph nodes.

Following are the different ways of treating thyroid cancer:

1. Surgery: In most of the cases, the entire thyroid gland is removed (thyroidectomy) along with the surrounding enlarged lymph nodes. In few cases, if the cancer is very small, only the affected lobe is removed.
2. Radioactive iodine therapy: After 4-6 weeks of surgery, this therapy is started in which the patient is given a pill of radioactive iodine to destroy any thyroid cancer tissue if present even after surgery.
3. Thyroid hormone therapy: Once the gland is removed, you need to supplement the body with thyroid hormone and hence one has to take this pill for lifetime after the operation. It replaces the need of thyroid hormone thyroxin and prevents the TSH levels from increasing which can stimulate any remaining cancer cells to grow.
4. External radiation therapy: This procedure is used if the patient cannot undergo surgery or if the cancer continues to grow after radioactive iodine therapy.
5. Chemotherapy: This modality of treatment uses potent drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.
6. Targeted drug therapy: It is therapy in which drugs are used such that they identify and attack the cancer cells without harming the normal cells. Sorafenib and sunitinib are the latest drugs being used to treat thyroid cancers [10].

Papillary and follicular thyroid cancers are the most common types of the thyroid cancer. Both these carcinomas have very good prognosis i.e. they are most curable ones. These carcinomas have 97% cure rate in younger patients when treated properly.

Medullary thyroid carcinoma is not seen much but has poor prognosis. This cancer spreads faster to the surrounding lymph nodes and hence requires more aggressive treatment.

Anaplastic thyroid cancer is rarely seen and has the worst prognosis. It is diagnosed after the spread has taken place and patient is almost incurable. It is rare to survive this cancer as many a times even the surgery cannot remove the tumor entirely.

The risk of developing thyroid cancer increases with benign thyroid conditions like thyroiditis or goitre. Exposure to radiation in childhood can increase the risk of developing thyroid malignancies, mainly papillary thyroid carcinoma. Exposure to radiations during medical procedures may also lead to thyroid cancer.

Inherited genetic mutations are responsible for a small number of medullary thyroid carcinomas. Low dietary intake of trace element iodine has higher chances of developing follicular or anaplastic carcinoma.

In 2010, thyroid cancer resulted in 36,000 deaths around the world as compared to 24,000 in 1990 [1]. Yearly, 1% new cases of thyroid cancer are diagnosed. The incidence of thyroid cancer is 3 folds more in females as compared to males. The prevalence of this disease is maximum in third and fourth decades of life.

The pathophysiology of thyroid cancer is not completely defined. Transformation of various molecular factors has been linked with thyroid malignancy. These include proliferative factors like growth hormones and oncogenes, and apoptotic and cell-cycle hindering factors such as tumor suppressors [2].

Physiological behavior of the cancer depends upon the type of tumor. Thyroid cancer is thought to follow a continuity from well differentiated to anaplastic, distinguished by early and late genetic events [3]. Many patients suffering from differentiated thyroid cancer experience loss of thyroid-specific functions such as iodine aggregation [4].

Papillary carcinoma arises from follicular cells, that produce and store thyroid hormones, have a tendency of spreading to local lymph nodes. Follicular carcinoma also arises from the follicular cells and Hurthle cell carcinoma is a rare type of follicular carcinoma that spread hematogenously.

Medullary thyroid cancer begins in thyroid cells called C cells that produce the hormone calcitonin. Anaplastic thyroid cancer is a rare, aggressive, undifferentiated carcinoma that is inclined to local invasion and metastatic spread.

Nodal spread is common with thyroid lymphoma which is a rare form of thyroid cancer that begins in the immune system cells in the thyroid and grows very quickly.

Exposure to radiation in early childhood is a known risk of thyroid cancer hence it is advised that children should not have any tests involving exposure to radiation unless it is absolutely essential.

Blood tests can be performed to look out for genetic mutations that are seen in familial medullary carcinoma as MTC can be treated early by removing the gland. Once the disease is discovered in the family, all the other family members should be tested for this mutated gene for prevention of cancer.

Thyroid cancer is a cancer arising from the follicular or parafollicular cells of the thyroid gland. Thyroid cancers can be divided into follicular carcinomas, papillary carcinomas, anaplastic carcinomas, primary thyroid lymphomas, medullary thyroid carcinomas (MTCs), and primary thyroid sarcomas.

Thyroid gland is an essential gland for the normal functioning of the body and hence prompt treatment of the thyroid cancer is needed. Like any other cancer the exact cause is known but childhood radiation has shown to be a risk factor and should be studiously avoided. Being diagnosed as a patient of thyroid cancer can be frightening, but thyroid cancer is curable most of the times.

The cancer is diagnosed by thyroid hormone tests, ultrasound of the neck and maybe CT or MRI scans too. There are various line of treatments that are available now a days to cure this disease.

Depending on the type and stage of cancer the physician guides you to the best mode of treatment that is appropriate for you. After the treatment you will have to take a pill to replace the thyroid hormone in your body for life time.

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3. Patel KN, Singh B. Genetic considerations in thyroid cancer. Cancer Control. 2006 Apr;13(2):111-118.
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5. Yip L, Wharry LI, Armstrong MJ, Silbermann A, et al. A clinical algorithm for fine-needle aspiration molecular testing effectively guides the appropriate extent of initial thyroidectomy. Ann Surg. 2014 Jul;260(1):163-8.
6. Kwon H, Kim WG, Choi YM, Jang EK, et al. A cut-off Value of Basal Serum Calcitonin for Detecting Macroscopic Medullary Thyroid Carcinoma. Clin Endocrinol (Oxf). 2014 Jul 19.
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9. Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ. 2013 Aug 27;347:f4706.
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