eMedicine Specialties > Oncology > Carcinomas of Endocrine Organs

Thyroid, Papillary 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; Andrew Scott Kennedy, MD, Co-Medical Director, Wake Radiology Oncology
Contributor Information and Disclosures

Updated: Aug 20, 2008

Treatment

Medical Care

The following medical care is appropriate for patients with papillary carcinoma, a relatively common well-differentiated thyroid cancer:

  • Approximately 4-6 weeks after surgical thyroid removal, patients must have radioiodine therapy to detect and destroy any metastasis and residual tissue in the thyroid. Administer therapy until radioiodine uptake is completely absent. Radioiodine treatment may be used again 6-12 months after initial treatment of metastatic disease where disease recurs or has not fully responded.  
  • When a large, unresectable tumor is present and the uptake of radioiodine is limited, when intractable bone pain exists, or if resection is not feasible, external beam radiation may be performed to control local tumor growth, including, but not limited to, the neck, lungs, mediastinum, bone, and CNS (stage T4).
  • Administer the thyroid hormone replacement levothyroxine to patients for life, especially after total thyroidectomy. Treatment consists of administering levothyroxine at 2.5-3.5 mcg/kg/d.
  • Chemotherapy with cisplatin or doxorubicin has limited efficacy, producing occasional objective responses (generally for short durations). Because of the high toxicity of chemotherapy with cisplatin or doxorubicin, chemotherapy may be considered in symptomatic patients with recurrent or advancing disease. However, chemotherapy could improve the quality of life in patients with bone metastases, but a standard protocol for chemotherapeutic management has not been developed for these patients.
  • A discussion of recently available targeted therapies for use in advanced differentiated thyroid cancer no longer responsive to radioablation may be found in the Chemotherapy section of Thyroid, Follicular Carcinoma.

See related CME at New Insights and New Challenges in Head and Neck Carcinoma.

Surgical Care

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

  • Lobectomy with isthmectomy: This procedure is the minimal operation for a potentially malignant thyroid nodule.
  • Subtotal thyroidectomy
    • This is a near-total thyroidectomy. The argument for this form of surgical intervention is that total thyroidectomy does not improve long-term prognosis and the incidence of complications (eg, hypoparathyroidism, superior and/or recurrent laryngeal nerve injury) is lower with subtotal thyroidectomy.
    • Patients younger than 40 years who have papillary thyroid carcinoma nodules that are smaller than 1 cm, well-defined, minimally invasive, and isolated may be treated with hemithyroidectomy and isthmectomy. However, an important consideration in considering this approach is that approximately 10% of patients who have had only a lobectomy develop a recurrence in the contralateral lobe, and residual tissue has the potential to dedifferentiate to anaplastic cancer.
  • Total thyroidectomy
    • Perform a total thyroidectomy (removal of all thyroid tissue but preserving the contralateral parathyroid glands) in patients who are older than 40 years with papillary carcinoma and in any patient with bilateral disease. In addition, recommend total thyroidectomy to any patient with a thyroid nodule and a history of irradiation. In papillary tumors of the thyroid, total thyroidectomy is the surgical treatment of choice for a number of reasons. Papillary foci involving both lobes are found in some 60-85% of patients. About 5-10% of recurrences in patients who have only had a lobectomy develop in the remaining lobe. Also, at 20 years after initial surgery, patients who had undergone total thyroidectomy had a recurrence rate of 8%, whereas those who had received only a lobectomy had a recurrence rate of 22%. Survival rates were, however, comparable.
    • This surgical procedure also facilitates earlier detection and treatment of recurrent or metastatic carcinoma. This surgical option is mandatory in patients with papillary carcinoma discovered based on postoperative histology findings (ie, if a very well-differentiated tumor is discovered) after a one-sided lobectomy, with or without isthmectomy.
    • When the primary tumor spreads outside the thyroid and involves adjacent vital organs (eg, larynx, trachea, esophagus), preserve these organs at the first surgical approach. However, the surrounding soft tissues, including the muscles and involved areas of the trachea and/or esophagus, may be sacrificed if they are directly involved with the differentiated thyroid carcinoma and local resection is feasible.
  • Video-assisted thyroidectomy: This is rarely used to treat thyroid cancer.
  • External beam radiotherapy: This has been used as adjuvant therapy in patients with papillary thyroid cancer who were older than 45 years and had locally invasive disease. Some improvements in 10-year survival rates have been reported with this approach.
 
See related CME at NCCN Thyroid Carcinoma Guidelines Update (Slides With Transcript).

Consultations

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

Medication

The most useful drugs for the treatment of papillary thyroid carcinomas (a relatively common well-differentiated thyroid cancer) after surgery are levothyroxine and radioiodine. For metastases, palliation with antineoplastic agents (eg, cisplatin, doxorubicin) may be useful.

Thyroid products

These drugs are useful to prevent hypothyroidism and to stop TSH stimulation.


Levothyroxine (Synthroid)

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

Cholestyramine may decrease absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants increased when coadministered; activity of some beta-blockers may decrease when hypothyroid patient is converted to a euthyroid state

Documented hypersensitivity; uncorrected adrenal insufficiency

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Maintain TSH at 0.1-0.2 mIU/mL; menopausal women may develop severe osteoporosis; caution in angina pectoris or cardiovascular disease

Antithyroid agents

These agents reduce serum thyroid hormone levels.


Sodium iodide I 131 (Iodotope)

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 µm. Results in destruction of all residual thyroid tissues, either pathologic or normal.

Adult

Nonmetastatic disease: 1110-3700 MBq (30-100 mCi) IV q3wk
Metastatic disease: 5550-7400 MBq (150-200 mCi) IV q3wk; discontinue treatment when scintigraphy findings negative

Pediatric

Not established

Increases lithium toxicity by producing additive hypothyroid effects; uptake is affected by stable iodine, thyroid, and antithyroid agents

Documented hypersensitivity; <35 y

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in pregnancy and breastfeeding 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, and hives

Antineoplastic agents

These medications inhibit cell growth and proliferation and may be helpful in palliating symptoms in progressive disease.


Cisplatin (Platinol)

Inhibits DNA synthesis and, thus, cell proliferation by causing DNA crosslinks and denaturation of double helix. Dose is 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

Reduce dose in renal failure; administer adequate hydration before and 24 h after cisplatin dosing to reduce risk of nephrotoxicity; myelosuppression, ototoxicity, nausea, and vomiting may occur


Doxorubicin (Adriamycin)

Inhibits topoisomerase II and produces free radicals, which may cause destruction of DNA. Combination of these 2 events, in turn, can inhibit growth of neoplastic cells.

Adult

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

Pediatric

Administer as in adults

Verapamil may increase cell toxicity; mercaptopurine increases toxicities; streptozocin inhibits metabolism; cyclophosphamide increases cardiac toxicity; cyclosporine may result in coma and/or seizure; phenobarbital increases elimination; decreases level 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 occur, resulting in severe tissue necrosis; caution in patients with impaired hepatic function; in the short-term, nausea and reddish stain of urine (not blood in urine) may occur; may cause toxicity to heart, oral mucosa, hair (alopecia), and hematopoietic system

More on Thyroid, Papillary Carcinoma

Overview: Thyroid, Papillary Carcinoma
Differential Diagnoses & Workup: Thyroid, Papillary Carcinoma
Treatment & Medication: Thyroid, Papillary Carcinoma
Follow-up: Thyroid, Papillary Carcinoma
References
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Further Reading

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Keywords

papillary thyroid carcinoma, papillary carcinoma, thyroid cancer, thyroid carcinoma, papillary/follicular carcinoma, papillary-follicular carcinoma, papillary cancer of the thyroid, follicular cancer of the thyroid, irradiation, radiation therapy, radiation exposure, ionizing radiation, radiotherapy, thyroid mass, thyroid nodule, thyroid lump, iodine deficiency, familial adenomatous polyposis, Gardner syndrome, Gardner's syndrome, Cowden disease, Cowden's disease, thyroid disease, thyroid disorders

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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.

Andrew Scott Kennedy, MD, Co-Medical Director, Wake Radiology Oncology
Andrew Scott Kennedy, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Hepato-Pancreato-Biliary Association, American Society for Therapeutic Radiology and Oncology, American Society of Clinical Oncology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, 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

 
 
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