19 answers found under All topics.

Q: How have the doctors listed in "Find a Thyroid Cancer Specialist Near You" been selected? For patients who must travel long distances to visit one of these centers, it can be hard to know whether it is worthwhile.

A: The physicians and surgeons listed in "Find a Thyroid Cancer Specialist Near You" have distinguished themselves by special commitment to thyroid cancer patient care, research, and teaching. These individuals practice in sophisticated medical centers with the multidisciplinary staff and facilities needed to provide comprehensive care for patients with thyroid cancer. There are certainly other doctors capable of treating thyroid cancer well. Our intent is simply to provide a list of the very best doctors and centers. For most thyroid cancer patients, an initial period of intense evaluation and treatment is followed by a successful outcome with relatively infrequent follow-up visits (every 6-12 months) for the long-term. Many patients and families think that it is worth travelling to be certain that the doctors caring for them will be the most up-to-date, skilled, and experienced ones that they could find. For the minority of thyroid cancer patients with disease that is aggressive or even currently incurable, it is particularly important to have access to the latest treatment options being investigated through research. We believe that the doctors and centers listed can provide that expertise.

Q: Is it recommended to obtain a second pathology report upon receiving the diagnosis of papillary carcinoma, folliculat variant of the thyroid? Are the variants of papillary carcinoma more aggresive or do they require different treatment protocols than papillary carcinoma?

A: In cases of suspected thyroid cancer, the diagnosis is ultimately established by a pathologist, a doctor who specializes in the examination of cells or pieces of tissue sampled during a biopsy or operation. The pathologist examines slides containing preparations of cells or slices of tissue under a microscope to determine whether there are findings typical of thyroid cancer. In most cases, the findings clearly indicate if the tissue is thyroid cancer or not. In some cases, however, the findings may be considered borderline. This is one situation when a second opinion from another pathologist with special expertise in thyroid cancer can help resolve the matter. Many referral centers also require that pathology specimens be re-examined at their institution before any major treatment, such as surgery or radioactive iodine, is carried out. This is important to avoid unfortunate mistakes. The process of obtaining a second pathology opinion involves collecting the original slides that contain preparations of cells or slices of tissues and transporting them to another facility so they can be examined. The decision about whether or not a second opinion is necessary in a given situation should made by the physician who is responsible for overseeing the evaluation and treatment of suspected thyroid cancer. There are certain special categories of papillary thyroid carcinoma (referred to as “variants”) that are distinguished on the basis of the appearance and organization of cells in pieces of tissue submitted for pathologic evaluation. Some of these variants are more aggressive than the most common type of conventional papillary thyroid carcinoma. Although these variants are treated similarly to treat the common form of papillary thyroid cancer, patients may require more “aggressive” treatment with more vigilant monitoring. The follicular variant of papillary thyroid carcinoma is the most common of the different variants currently recognized. It is characterized by cells that are arrayed in spherical formations called "follicles". This variant behaves in a manner that is indistinguishable from the conventional form of papillary thyroid cancer, and it is associated with a similar, generally favorable prognosis. The tall cell variant is an uncommon form of papillary thyroid carcinoma is characterized by cells that are at least twice as tall as they are wide, with other specific features that can be identified on microscopic examination. This variant tends to occur in older individuals. Tall cell papillary cancers tend to be larger and are more likely to spread to invade lymph nodes or other structures in the neck. This variant is more aggressive than the common form of papillary thyroid cancer and is associated with a higher rate of recurrence, particularly in older individuals. The columnar cell variant of papillary thyroid carcinoma is very rare. It is characterized by cells that are at least three times as tall as they are wide, with other specific features that can be identified on microscopic examination. Columnar cell papillary cancers tend to be larger and are more likely to spread to invade other structures in the neck and other sites in the body. This variant is significantly more aggressive than the common form of papillary thyroid cancer, with a higher risk of recurrence.

Q: I was surprised to find out on Monday of this week that I had thyroid cancer. Even of greater surprise was to discover on Thursday that I was pregnant! What can I expect as a course of treatment to keep me healthy and my unborn child too?

A: There are several special considerations when thyroid cancer is discovered in a woman who is pregnant. First, a decision must be made whether to perform surgery to remove the thyroid gland during pregnancy or whether to wait until after the baby is delivered. Surgery during pregnancy may be advisable if a thyroid cancer is large, appears to be a more aggressive variant, or has already spread to other sites in the neck or elsewhere in the body. If surgery during pregnancy is indicated, it is usually performed during the second trimester (i.e., months 4-6 of pregnancy). This timing has the least chance of interfering with the baby’s early development or causing premature labor. On the other hand, delaying surgery until after delivery is often a reasonable choice if the thyroid cancer is small and there is no evidence of aggressiveness or spread. Delayed surgery may also be best if other aspects of the pregnancy increase the risk of performing an operation. Small studies have shown that delaying surgery does not increase the risk of spread, recurrence, or death in pregnant women with papillary thyroid cancer. During pregnancy, whether surgery is performed then or not, treatment with thyroxine should be started. This ensures that thyroid cancer tissue will be “put to rest” until surgery can be performed. Free T4 and TSH lab tests should be done every 1 to 2 months to ensure that the dose of medication is just high enough to suppress TSH. After delivery and surgery, a decision must be made about whether to give radioactive iodine treatment. Radioactive iodine must not be given during pregnancy, as it can damage the fetus' thyroid gland. Similarly, radioactive iodine cannot be given until the mother has stopped nursing her baby. It may be advisable to wait several months after breastfeeding, since breast tissue that is active concentrates more radioactive iodine within itself.

Q: For recurrent, resistant papillary thyroid cancer, which type of external beam radiation is the most effective and does the least amount of damage to the esophagus?

A: Two types of external beam radiotherapy (EBRT) are typically used for thyroid cancer: photon and electron beam. Proton beam therapy is only available in two sites at the U.S. and is rarely used for patients with thyroid cancer. There are new and different ways to apply photon EBRT. The descriptive terms you may have heard are: "3-D", "conformal", or "IMRT" (Intensity Modulated Radiation Therapy). These methods allow the radiation oncologist to tailor the radiation treatment with greater precision than was possible utilizing the standard "2-D" methods. This permits either: 1) a higher dose to a tumor for the same degree of normal tissue toxicity as was experienced with "2-D' methods; or, 2) the same dose that has always been used, but with less normal tissue toxicity. All of these photon beam methods should be equally effective in treating recurrent, treatment resistant thyroid cancer if the same dose to tumor is given; however, the various newer 'conformal' techniques may allow a slightly higher dose and a possibly better outcome. EBRT causes pain in the esophagus during and shortly after the EBRT is completed. Swallowing function may occasionally be somewhat impaired after EBRT. One should not necessarily expect less esophageal pain if 'conformal' methods are used to treat thyroid cancer. Generally, recurrent and treatment-resistant thyroid cancer will be present in tissues adjacent to the esophagus and the windpipe or may be adherent to them. It will sometimes be behind them and in front of the backbone. In these circumstances, the radiation beams need to cover the all of the windpipe and esophagus, so that there is still the same degree of esophageal pain as with '2-D' techniques.

Q: I just had my thyroid removed because of thyroid cancer, so I will need thyroid medication from now on. I have been reading about the possible shortcomings of thyroxine (T4) for thyroid hormone replacement, and about the use of desiccated (Armour) thyroid as an alternative. What are the facts?

A: For patients who have had thyroidectomy for thyroid cancer, there are two reasons that lifelong thyroid hormone replacement is vital. First, it replaces the thyroid hormone that the gland is no long present to provide. Second, it suppresses the pituitary gland's production of thyroid-stimulating hormone (TSH), which can otherwise promote th regrowth of thyroid cancer. For virtually all patients, thyroxine (T4) is the drug of choice. The normal thyroid itself makes mainly T4, which is then converted to the more active thyroid hormone T3 in target tissues, like the brain, heart, liver, and skin. T4 mimicks this natural process. It also has a stable level in blood and steady tissue action, even when taken just once per day. In contrast medications containing T3, like desiccated thyroid, can cause ups and downs in T3 levels and actions during the course of the day. Because desiccated thyroid also contains T4, which is then converted to more T3, the T3 level is above normal for at least part of the day in most patients. This can sometimes cause nervousness, insomnia, palpitations, tremor and fatigue. In the long-term, it can predispose to bone mineral loss (osteoporosis) and an irregular heart rhythm called atrial fibrillation. There can a temporary use for T3 therapy: when thyroid hormone must be opped for radioiodine scanning and treatment. Its faster offset of action shortens the period of thyroid hormone deficiency. In other settings, thyroxine (T4) is the most stable, effective, and safe form of thyroid hormone replacement. Its conversion to T3 in target tissues also makes it the most "natural" way to replace the function of the missing thyroid gland.

Q: How often and how long after receiving radioactive iodine (to destroy remaining thyroid tissue after surgery) do patients feel pain in their throats from the thyroid tissue that is dying?

A: When radioactive iodine is used to destroy the thyroid tissue that often remains after surgery, the electrons (beta particles) that 131-iodine emits inflame and ultimately kill thyroid cells. For most patients, this "radiation thyroiditis" is completely painless. Approximately 20% of patients may experience some mild aching as a result. This pain may be over the thyroid gland (i.e., beneath the Adam's apple in the front of the neck), or it may seem to come from the throat, jaw or ear. The pain is almost always mild and easily relieved by a mild pain-reliever like acetominophen (Tylenol) or anti-inflammatory dug like ibuprofen (Motrin or Advil). When it occurs, the pain typically has its onset from 1 to 7 days after radioactive iodine, and then resolves after 1 to 5 days.

Q: How long after surgery to remove the thyroid gland should thyroid hormone medication be started?

A: When and what kind of thyroid hormone therapy should be started after thyroid surgery depends on whether cancer has yet been confirmed and whether radioactive iodine treatment is planned. If a diagnosis of thyroid cancer has been confirmed and there are plans to proceed with radioactive iodine treatment, some practitioners may delay starting thyroid hormone therapy altogether after surgery to promote the TSH production that maximizes uptake of radioactive iodine. Alternatively, clinicians will start patients on a brief course of triiodothyronine (T3, Cytomel), a shorter-acting thyroid hormone that is then stopped about two weeks before planned radioactive iodine treatment. If a diagnosis of thyroid cancer has been confirmed but there are no plans to proceed with radioactive iodine treatment, thyroid hormone replacement therapy can be started right after surgery as soon as a patient is able to swallow tablets. Levothyroxine (T4) is usually started at a dose targeted to lower TSH, to a level that depends on the particular tumor being treated. A TSH level should usually be checked 4-6 weeks after levothyroxine has been started to see if the dose is adequate. If a final diagnosis has not yet been confirmed, it is usually okay to wait a few days before deciding whether or not to start any type of thyroid hormone therapy. In most cases, patients have sufficient stores of thyroid hormone to last for up to a week before levels drop and symptoms develop.

Q: Can a pleural effusion be due to metastatic thyroid cancer?

A: Metastatic thyroid cancer very rarely causes a pleural effusion. This invariably occurs with known or easily demonstrated lung metastases. In their absence, other causes of pleural effusion should be seriously considered.

Q: I had an insular thyroid cancer removed surgically. I would like more information on this type of tumor. Specifically, what is life expectancy for patients with this condition?

A: Insular thyroid carcinoma is a type of thyroid cancer that falls somewhere between the extremes of well-differentiated thyroid cancers, which are slow growing and almost always curable, and poorly differentiated (including anaplastic) thyroid cancer, which are rapidly progressive and seldom effectively treated. Thyroid cancers can be classified by how much cells in a tumor resemble normal thyroid tissue when examined under the microscope. Tumors that are made up of cells that have grown to the normal mature stage of development are classified as well differentiated cancers. These tumors tend to grow fairly slowly, and they usually respond to treatment with surgery, radioactive iodine, and thyroid hormone. Papillary thyroid carcinoma and follicular thyroid carcinoma are the most common types of differentiated cancers. Tumors that are made up of cells that do not mature normally are classified as poorly differentiated or undifferentiated cancers. These tumors tend to grow more rapidly and to spread beyond the thyroid gland to nearby tissue in the neck and to other parts of the body. They usually do not respond to treatment with radioactive iodine. Anaplastic thyroid carcinoma is the most aggressive form of such undifferentiated thyroid cancers. Insular thyroid cancer, most of the tumor appears well differentiated, but there are “islands” of poorly differentiated cells within the tumor. Insular thyroid carcinomas may represent between 1-5% of all thyroid cancers. Survival rates appear to fall somewhere in between the better rates associated with well differentiated cancer and the worse rates associated with undifferentiated cancer. Overall, about 98% of individuals with well differentiated cancers survive longer than 15 years from the time of diagnosis. In contrast, only 3-17% of individuals with undifferentiated cancers survive longer than 5 years from the time of diagnosis.

Q: After being diagnosed with papillary thyroid cancer 7 years ago, I had surgery and two radioactive iodine treatments. Two years later, there was no uptake on my scan. I recently had a scan with Thyrogen stimulation that also came back negative, but my thyroglobulin level was 220 [mg/ml]. In order to find out where the remaining thyroid tumor is, ny doctors performed a PET et scan last week that was negative and now I am going off my medicine for a month and having a new scan. I really dont understand where the cancer can be, and how will they find i? They are doing another scan after I stop by thyoid hormone and will most probably give me another dose of radioactive iodine. I feel like a real mystery. What should be done? Thank You

A: Since thyroid cancer can recur even years after primary treatment. So it is important for patients to be followed carefully for the rest of their lives. For most patients, this follow-up should include doctor visits every 6 to 12 months, at which time the doctor can check to see if any suspicious symptoms have developed and examine the neck carefully. In addition, most patients will periodically have two tests. The first is a blood test to detect thyroglobulin, a protein that is only made by thyroid cells. None should be around if all normal thyroid tissue and tumor has been eradicated. This test is quite sensitive, but is even more accurate when it is done after TSH stimulation, either following discontinuation of thyroid hormone or after Thyrogen (i.e., recombinant TSH). The second test to detect thyroid tumor tissue that remains or has regrown is the radioactive iodine whole body scan, which must always be performed after TSH stimulation. Some patients with remaining tumor will have positive findings in both tests--thyroglobulin and scanning. But as many as 20% of patients with remaining tumor will only have detectable thyroglobulin with a negative radioiodine scan. (Patients with a positive scan and negative thyroglobulin also occur, but this circumstance is much rarer.) When the thyroglobulin indicates remaining tumor tissue, but the raiodactive iodine scan is negative, there are a number imaging techniques that can help find the tumor. The most useful initial test is a sonogram of the neck, since remaining tumor is most likely to be in lymph nodes near where the thyroid was located. If this shows enlarged lymph nodes, they can be biopsied under sonographic guidance. If the sonogram is negative, then a CT scan of the chest can sometimes reveal tumor there. CT and MR examinations of the neck and other suspicious areas can also sometimes be useful. Many experts now believe that PET scanning (specifically fluourodeoxyglucose positron emission tomography) is the best available test for detecting tumor that has not been found by sonography in the neck. If all of these tests are negative, then many specialists think it is helpful to go ahead with another radioactive iodine treatment after stopping thyroid hormone. Even though the previous diagnostic scan, which is typically done with only 5 to 10 millicuries of 131-I, has been negative, about 25% of patients will have a low level of radioactive iodine uptake in tumor tissue when a post-treatment scan is done 4 to 10 days after the larger (150 to 200 millicuries) 131-I treatment dose.

Q: My dad has papillary thyroid cancer with metastases to the lungs. He now has fluid in one of his lungs. Is there a medical term for "fluid in the lungs"?

A: Yes. It is called a "malignant pleural effusion."

Q: Will I have difficulty getting pregnant as a result of having thyroid cancer and being treated for it?

A: Having had thyroid cancer should not interfere with a woman's ability to have a normal pregnancy and baby. Sometimes, however, plans for pregnancy must be postponed so that needed surgery, scanning, and radioiodine therapy can be safely given. Although thyroid surgery can be performed during the middle of pregnancy, it is not wise to become pregnant when the need for thyroid surgery is known in advance. Radioiodine scanning and treatment should never be done in pregnant women because the radioactive iodine reaches the fetus and can injure its thyroid gland. Different doctors and institutions have different policies about wow long after radioiodine treatment a woman should wait to become pregnant. Although the radioiodine is essentially gone from a woman's body within 3 to 4 weeks, thyroid hormone medication must then be started and can take 1 to 3 months to be well adjusted. At our center, we recommend that women anticipate it will be 3 to 6 months after radioiodine treatment before they should plan pregnancy. While on thyroid hormone therapy, women typically can become pregnant as easily as they might otherwise. But occasionally, normal ovulation and menstrual periods can be disrupted by the relatively high level of thyroxine that is prescribed as a part of thyroid cancer therapy. In these women, the dose of thyroxine may have to be temporarily adjusted downwards. There is no evidence that previous thyroid cancer, thyroid surgery, or radioiodine treatment increase the likelihood of birth defects in the children of women who have been treated thyroid cancer.

Q: Should thyroxine treatment be changed when a woman becomes pregnant?

A: First, it is very important that women who are taking thyroxine continue it faithfully when they become pregnant. Thyroxine medication is exactly like what the mother's own gland would be making to ensure normal fetal nervous system development in the first part of pregnancy. Second, more than half of women need an increase the dose of thyroxine during pregnancy because the hormone is broken down more rapidly. The increase required can be as much as 50-100%, and it can occur in the early, middle or late part of pregnancy. Consequently, most thyroid experts recommend that women taking thyroxine have a TSH measurement done as soon as they know they are pregnant, and then again at 4 and 7 months of pregnancy. If at any point the TSH is higher than the goal for treatment, the thyroxine dose should be increased, usually by 25-50 micrograms per day, with a follow-up TSH measurement one month later.

Q: Should patients with thyroid cancer see an Endocrinologist or an Oncologist for treatment?

A: It depends, of course, on the specific Endocrinologist or Oncologist's knowledge, skills, experience, and interest in treating thyroid cancer. In most parts of North America, Endocrinologists are more likely to diagnose and manage patients with thyroid cancer--often as part of a team including surgeons and nuclear medicine or radiation oncology specialists. There are a few simple questions that might help patients decide whom to see: 1. How many new thyroid cancer patients do you see each year? 2. For how many thyroid cancer patients are you now the "point person" directing treatments and monitoring. 3. Who works with you in managing your patients with thyroid cancer?

Q: Is Thyrogen appropriate to scan people who have had papillary thyroid cancer, but not yet had a clean I-131 scan?

A: Most experts would currently say, "It depends... ." First, it depends on the patient's likelihood of having residual or recurrent thyroid cancer, based on their age and the characteristics of their tumor, including its size, whether there was local tissue invasion beyond the thyroid or distant metastases, the completeness of tumor removal at surgery, and specific features of the tumor under the microscope. In patients at higher risk (e.g., a 64-year-old person with a 4 cm. tumor invading local muscle), many physicians would recommend that Thyrogen be used only after one cycle of radioiodine scanning and thyroglobulin measurement after thyroid hormone withdrawal were completely negative. Second, withdrawal testing is usually favored as long as there is a good chance that testing will show that another radioiodine treatment will be needed, since Thyrogen is not yet approved by the FDA to facilitate radioiodine therapy, as opposed to diagnostic testing. Third, in patients with anti-thyroglobulin antibodies in their blood, thyroglobulin itself cannot be measured accurately. Consequently, patients and their doctors must rely on radioiodine scanning alone to detect thyroid cancer. When only scanning can be done (without thyroglobulin testing), thyroid hormone withdrawal has been shown to be slightly more sensitive than Thyrogen in detecting remaining thyroid tissue. (In contrast, when both radioiodine scanning and thyroglobulin testing can both be done, Thyrogen testing has been shown to be just as accurate.) Since doctors are still learning how to use Thyrogen in the best way possible, patients will find some differences of opinion among respected experts. And recommendations about the very best approach to follow-up testing can be expected to evolve over time.

Q: I know TSH suppression is important. However, whenever my TSH gets even close to 0.6 mU/L (which is not very suppressed), I get palpitations. Should I just live with this or will the symptoms disappear?

A: You are right that keeping the blood TSH level low is an important part of preventing recurrent thyroid cancer. Just how low and for how long depends on two factors. First, how likely is it that a particular patient's tumor will recur, based on their age and characteristics of the tumor itself (including its size, whether there was local tissue invasion beyond the thyroid or distant metastases, the completeness of tumor removal at surgery, and specific features of the tumor under the microscope). Second, the "aggressiveness" with which TSH suppression should be done depends on the patient's susceptibility to problems related to thyroid hormone excess. For example, some patients with heart disease do not tolerate even a high-normal thyroxine dose well. Some women after the menopause may suffer bone loss as a result of having their TSH suppressed to less than 0.1 mU/L for years. And some patients are simply more susceptible to symptoms, such as palpitations, nervousness, or trembling hands. Sometimes other medication (beta-blockers) can be used to control these symptoms, but sometimes one simply has to compromise on the thyroxine dose. In this matter, as in so many related to thyroid cancer, treatment must be individualized by a physician who is knowledgeable, skilled, and experienced in managing patients with the condition.

Q: Can people adjust their diet, exercise, and other aspects of lifestyle to keep their thyroid gland in good shape?

A: Unlike heart disease and some forms of cancer, there is relatively little known about things a person can do in terms of diet, exercise, or lifestyle to ensure good thyroid health. Nonetheless, there are a few steps worth taking. Avoid smoking, which has been associated with greater risk of hyperthyroid Graves' disease, especially its eye involvement. Eat a balanced diet with sufficient foods containing iodine (such as iodized salt, seafood, milk products, and commercially baked bread). For patients with a family history of thyroid problems or an enlarged thyroid, it is usually wise to avoid very large amounts of iodine, such as can be found in kelp, certain cough syrups, and some prescribed medications (e.g., amiodarone, which is used to control abnormal heart rhythms). Finally, patients with a family history of thyroid cancer, a new lump in the neck, and certain local symptoms (e.g., pain in the front of the neck or hoarseness for more than two weeks), should see their doctor to be evaluated.

Q: Are there ways to help heal the incision from thyroid surgery? Should there be follow-up cosmetic surgery for the scar?

A: Thyroid surgery is usually followed by excellent wound healing. In the vast majority of cases, there is a satisfactory cosmetic result. Because of the extensive blood supply in the neck and the fact that thyroid surgery is "clean" (i.e., No contaminated body cavities are explored), infection should be rare. Avoiding sun exposure is wise to promote smooth wound healing. Beyond that, no special wound care is required following thyroid surgery. There are no controlled trials proving that any topical or injected agents are beneficial. In spite of the excellent results obtained in most patients, a few may not satisfied with the appearance of their scars. For some of these patients, plastic surgery can be helpful, but cosmetic procedures are rarely indicated until at least six months after the initial procedure.

Q: I have a 1/2 inch solid thyroid nodule. Should I opt for a fine needle aspiration or radioiodine scan first? I want to take the most prudent and cost-effective route to health.

A: After a clinical assessment (i.e., talking with and being examined by your doctor), patient's with a thyroid nodule should generally then have a TSH blood test. If the TSH is normal, the fine needle aspiration biopsy is almost invariably the test that should be done next. It is the most accurate, prompt, and cost-effective way to establish a diagnosis. On the other hand, if the serum TSH is low (e.g., less than 0.1 mU/L), then it is often best to perform a radionuclide thyroid scan next, using either 123-Iodine or 99m-Technetium pertechnetate. This is because a low TSH level may be indicate that the nodule is "hot," producing excessive thyroid hormone and suppressing the rest of the gland. Such nodules may need treatment for their overactivity, but they are almost never cancers. For further information on this website, check out the "What's Your Situation" section entitled "How are thyroid nodules evaluated?"