eMedicine Specialties > Oncology > Carcinomas of Endocrine Organs

Thyroid, Follicular Carcinoma: Treatment & Medication

Author: Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Coauthor(s): Silvia Gagliardi, MD, Consulting Staff, Department of Surgery, Medical Center Vita, Italy; Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine; Division Chief, Senior Adult Oncology Program, H Lee Moffitt Cancer Center and Research Institute
Contributor Information and Disclosures

Updated: Sep 25, 2009

Treatment

Medical Care

The initial treatment for cancer of the thyroid is surgical. The exact nature of the surgical procedure to be performed depends for the most part on the extent of the local disease. A consensus approach might be to perform a total thyroidectomy if the primary tumor is larger than 1 cm in diameter or if there is extrathyroidal involvement or distant metastases. Clinically evident lymphadenopathy should be removed with a neck dissection. If the primary tumor is less than 1  cm in diameter, a unilateral lobectomy might be considered. About 4-6 weeks after surgical thyroid removal, patients must have radioiodine to detect and destroy any metastasis and any residual tissue in the thyroid. Administer therapy until no further radioiodine uptake is noted.

  • Patients take thyroid replacement therapy (ie, L-thyroxine [L-T4]) for life. This entails taking 2.5-3.5 mcg/kg of L-T4 every day. The thyroxine is given in the dose necessary to inhibit thyrotropin to a value of 0.1-0.5 mU/L. This treatment plan is generally successful. However, a 10-year recurrence rate of 20-30% may be seen in older patients, in patients with primary tumors greater than 4 cm in diameter, and in patients where tumor has spread beyond the thyroid boundaries and where lymph node involvement is widespread. Once metastatic thyroid cancer becomes resistant to radioiodine, the 10-year survival is less than 15%.
  • A number of indications for external beam radiation therapy (EBRT) apply to the management of FTC.
    • If all gross disease cannot be resected, or if residual disease is not avid for radioactive iodine, EBRT is often employed for locally advanced disease.
    • Similarly, radiation therapy is indicated for unresectable disease extending into adjacent structures, such as the trachea, esophagus, great vessels, mediastinum, and/or connective tissue. In this situation, radiation therapy doses of 6000-6500 cGy are typically used.
    • Following radiation therapy for unresectable disease, the patient should undergo I-131 scanning. If uptake is detected, a dose of I-131 should be administered.
    • EBRT increases the local-regional control of the residual disease for patients with locally advanced differentiated thyroid carcinoma.14
    • EBRT also may be used after resection of recurrent FTC that is no longer avid for radioactive iodine.
    • In the postoperative setting, radiation therapy doses of 5000-6000 cGy are commonly delivered to the tumor bed to reduce the risk of local-regional recurrence.
    • Careful treatment planning (typically with multiple radiation therapy fields) should be employed to minimize the risks of radiation therapy complications.
    • Finally, a palliative course of radiation therapy is useful to relieve pain from bone metastases.
  • Chemotherapy with cisplatin or doxorubicin has limited efficacy, producing occasional objective responses (generally for short durations). Because of the high toxicity of cisplatin and doxorubicin, chemotherapy may be considered in symptomatic patients with recurrent or progressive disease. It could improve quality of life in patients with bone metastases. No standard protocol exists for chemotherapy of metastatic FTC.
  • FTC is a highly vascular lesion. In patients with bone metastases who experience severe pain that does not respond to palliative radiation, arterial embolization of the tumor might be considered.

Surgical Care

Surgery is the definitive management of thyroid cancer, and various types of operations may be performed.

  • Lobectomy with isthmectomy
    • This represents the minimal operation for a potentially malignant thyroid nodule.
    • Patients younger than 40 years who have FTC nodules that are less than 1 cm in size, well defined, minimally invasive, and isolated may be treated with hemithyroidectomy and isthmectomy.
  • Subtotal thyroidectomy (near-total thyroidectomy)
    • Subtotal thyroidectomy is preferable if it is feasible, since it carries a lower incidence of complications (eg, hypoparathyroidism, superior and/or recurrent laryngeal nerve injury).
    • Moreover, total thyroidectomy does not improve the long-term prognosis.
  • Total thyroidectomy (removal of all thyroid tissue, with preservation of the contralateral parathyroid glands)
    • Approximately 10% of patients who have had total thyroidectomy demonstrate cancer in the contralateral lobe. Therefore, residual thyroid tissue has the potential to dedifferentiate to anaplastic cancer.
    • Perform total thyroidectomy in patients who are older than 40 years with FTC and in any patient with bilateral disease; furthermore, recommend total thyroidectomy to anyone with a thyroid nodule and a history of irradiation.
      • Some studies show lower recurrence rates and increased survival rates in patients who have undergone total thyroidectomy.
      • This surgical procedure also facilitates earlier detection and treatment of recurrent or metastatic carcinoma.
      • This surgical option is mandatory in patients with FTC ascertained by postoperative histologic studies (ie, if a very well-differentiated tumor is discovered) after a one-side lobectomy, with or without isthmectomy.
  • When the primary tumor has spread outside the thyroid and involves adjacent vital organs, such as the larynx, trachea, or esophagus, preserve these organs at the first surgical approach. However, the surrounding soft tissues, including muscles and involved areas of the trachea and/or esophagus, may be sacrificed whenever they are involved directly in the differentiated thyroid carcinoma and their local resection is easily feasible. Surgical resection of one or more brain metastases may prolong survival from 4 to 22 months.

During the last decade, a number of minimally-invasive endoscopic approaches have been proposed for the treatment of thyroid carcinoma, but these techniques may be applied only to a small number of cases — those classified as 'low risk' carcinomas according to the AGES and AMES classifications.

Consultations

  • Schedule elderly patients for cardiologic assessment because of the high risk of subclinical hypothyroidism episodes.
  • Consult an otolaryngologist, especially in patients with thyroid disease who have voice disturbances.

Diet



Medication

The most useful drugs for postsurgical treatment of FTC are L-thyroxine (L-T4) and radioiodine. Antineoplastic drugs such as cisplatin and doxorubicin may be useful for palliation in patients with metastases.

Thyroid products

These agents treat thyroid hormone deficiency.


L-T4, L-thyroxine, levothyroxine (Synthroid)

Useful for prevention of hypothyroidism and to stop TSH stimulation. In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development.

Adult

3-3.5 mcg/kg/d PO for life

Pediatric

Neonate to 6 months: 25-50 mcg/d
6-12 months: 50-75 mcg/d
1-5 years: 75-100 mcg/d
6-12 years: 100-150 mcg/d
>12 years: 150 mcg/d

Cholestyramine may decrease absorption; estrogens may decrease response in patients with nonfunctioning thyroid glands; increases effects of anticoagulants; on conversion from hypothyroid to euthyroid may decrease activity of some beta-blockers

Documented hypersensitivity; uncorrected adrenal insufficiency

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Maintain TSH between 0.1-0.2 mcIU/mL; menopausal women may develop severe osteoporosis (bone loss); caution in angina pectoris or cardiovascular disease

Antithyroid drug

These agents reduce serum thyroid hormone levels.


Iodine 131, Radioiodine (131-I) (Sodium iodine 131)

Radioiodine is taken up by thyroid tissue and cannot be used in metabolic pathways. Emits beta and gamma radiation that causes destruction of thyroid tissue along a diameter of 400-2000 mcm. Results in destruction of all residual thyroid tissues, either pathologic or normal.

Adult

Nonmetastatic disease: 30-100 mCi IV q3wk
Metastatic disease: 150-200 mCi IV q3wk; treatment ends when scintigraphy is not positive

Pediatric

Not established

Uptake is affected by stable iodine, thyroid, antithyroid agents

Documented hypersensitivity; <35 y

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Pay attention during pregnancy and lactation because drug may pass through placenta and is secreted into milk; may cause bone marrow depression, acute leukemia, anemia, blood dyscrasias, leukopenia, thrombocytopenia, radiation sickness, angina, sinus tachycardia, pruritus, skin rash, hives

Antineoplastic drugs

These agents inhibit cell growth and proliferation.


Cisplatin (Platinol)

May be helpful in palliating symptoms in patients with progressive disease. Like other antiproliferative drugs, dosage related to body surface area.

Adult

20-40 mg/m2/d IV for 3-5 d q3wk
Alternatively: 20-120 mg/m2 IV once q3wk

Pediatric

Not established

Increases toxicity of bleomycin and ethacrynic acid

Documented hypersensitivity; preexisting renal insufficiency; myelosuppression; hearing impairment

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Dosage must be reduced in patients with renal failure; administer adequate hydration before and 24 h after infusion to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, nausea, and vomiting may occur


Doxorubicin (Adriamycin)

As reported for cisplatin, may be helpful in palliating symptoms in patients with progressive disease. Dosage related to body surface area.

Adult

60-75 mg/m2 IV single dose q3-4wk; total dose not to exceed 550 mg/m2

Pediatric

Administer as in adults

Verapamil may increase cell toxicity; mercaptopurine worsens toxic effects; streptozocin inhibits metabolism of doxorubicin; cyclophosphamide increases cardiac toxicity; cyclosporine may result in coma and/or seizure; phenobarbital increases elimination; decreases levels of digoxin and phenytoin

Documented hypersensitivity; severe CHF; cardiomyopathy; preexisting myelosuppression; impaired cardiac function; previous treatment with complete cumulative doses of doxorubicin, idarubicin, and/or daunorubicin

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Extravasation may result in severe tissue necrosis; caution in patients with impaired hepatic function; at short term, nausea and reddish stain of urine (it is not blood in urine) may occur; may cause toxicity to heart, oral mucosa, hair (alopecia), and hematopoietic system

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References
Further Reading
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Further Reading

The progress of the knowledge in molecular bases of thyroid cancers offers new therapeutic targets for FTC treatment and, in the future, prevention. A recent, interesting paper on this subject is Molecular genetics of thyroid cancer: implications for diagnosis, treatment and prognosis from MN Nikiforova and YE Nikiforov (Expert Review of Molecular Diagnostics, January 2008, Vol. 8, No. 1, Pages 83-95).

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Keywords

follicular thyroid carcinoma, FTC, thyroid cancer, thyroid cancer treatment, thyroid cancer medications, thyroid cancer diagnosis, thyroid cancer symptoms, thyroid cancer pictures, Hürthle cell carcinoma, Hurthle cell carcinoma, papillary carcinoma, tumor

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Contributor Information and Disclosures

Author

Luigi Santacroce, MD, Assistant Professor, Medical School, State University at Bari, Italy
Disclosure: Nothing to disclose.

Coauthor(s)

Silvia Gagliardi, MD, Consulting Staff, Department of Surgery, Medical Center Vita, Italy
Disclosure: Nothing to disclose.

Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine; Division Chief, Senior Adult Oncology Program, H Lee Moffitt Cancer Center and Research Institute
Disclosure: Nothing to disclose.

Medical Editor

Philip Schulman, MD, Chief, Medical Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center; Clinical Professor, Department of Medicine, New York University School of Medicine
Philip Schulman, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology, and Medical Society of the State of New York
Disclosure: celgene Honoraria Speaking and teaching; Amgen Honoraria Speaking and teaching; genetech/idec Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting; FibroGen Consulting fee Consulting

 
 
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