Papillary Thyroid Carcinoma Workup

  • Author: Keith M Baldwin, DO; Chief Editor: Jules E Harris, MD, FACP, FRCPC  more...
Updated: Sep 22, 2016

Approach Considerations

The following workup should be considered for the diagnosis of papillary carcinoma, a relatively common well-differentiated thyroid cancer:

  • Thyroid function studies
  • TSH suppression test
  • Thyroid ultrasound
  • Fine-needle aspiration biopsy (FNAB)

If possible, assessment of the RET proto-oncogene expression should be performed in any patient having a relative with a history of papillary thyroid cancer. Papillary thyroid cancer is strongly associated with some specific rearrangements of RET.[33]

The serum level of carcinoembryonic antigen (CEA) can be measured (reference range is < 3 ng/dL). However, the implications of an elevated CEA level are not specific; CEA levels are high in several cancers, and numerous healthy people may have small amounts of CEA, especially pregnant women and persons who are heavy smokers.


FNAB is considered the best first-line diagnostic procedure for a thyroid nodule. A thyroid biopsy can also be performed using the classic Tru-Cut or Vim-Silverman needles, but the FNAB technique is preferable. Patients comply best with FNAB.

Perform indirect or fiberoptic laryngoscopy to evaluate airway and vocal cord mobility and to have preoperative documentation of any unrelated abnormalities.

Imaging studies

Chest radiography, computed tomography (CT), and magnetic resonance imaging (MRI) are not usually used in the initial workup of a thyroid nodule. National Comprehensive Cancer Network (NCCN) guidelines recommend CT or MRI for the evaluation of fixed, bulky, or substernal lesions.[7] Chest x-ray may be considered in patients with apparent metastatic disease at presentation.

A study by Choi et al concluded that preoperative [18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET)/CT did not provide any additional information compared with neck sonography in patients with papillary thyroid carcinoma.[34]

Cabrera et al reported that single-photon emission computed tomography (SPECT)/CT and radioguided sentinel lymph node biopsy (rSLNB) can affect therapy by detecting occult cervical lymph node metastases in patients with papillary thyroid carcinoma. In their study, rSLNB results prompted management changes in 14 of 37 patients, with use of higher radioiodine ablation doses and closer clinical surveillance.[86]


Thyroid Function Studies

Perform a complete assessment of thyroid function in any patient with thyroid nodules. No available blood tests are specific for papillary cancer of the thyroid. Higher-than-normal levels of thyroxine (reference range is 4.5-12.5 mcg/dL), triiodothyronine (reference range is 100-200 ng/dL), and thyroid-stimulating hormone (TSH) (reference range is 0.2-4.7 mIU/dL) may or may not be associated with thyroid cancer.

Evaluate serum levels of thyroglobulin. Calcium and calcitonin may be elevated in medullary carcinoma of the thyroid.

TSH suppression test

Thyroid cancer is autonomous and does not require TSH for growth, whereas benign lesions do require TSH. When exogenous thyroid hormone feeds back to the pituitary to decrease the production of TSH, thyroid nodules that continue to enlarge are likely to be malignant. However, 15-20% of malignant nodules are suppressible.

Preoperatively, the TSH suppression test is useful for patients with nontoxic solitary benign nodules and for women with repeated nondiagnostic test results. Postoperatively, the test is useful for monitoring papillary thyroid cancer cases.


Thyroid Ultrasound

Thyroid ultrasound is the first imaging study to perform in any patient with possible thyroid malignancy. Ultrasound is noninvasive and inexpensive, and it represents the most sensitive procedure for identifying thyroid lesions and for determining the diameters of a nodule.

Ultrasound is also useful for localizing lesions when a nodule is difficult to palpate or is deeply seated. The images can help determine if a lesion is solid or cystic and can help detect the presence of calcifications.

Ultrasound may be used to help direct a fine-needle aspiration biopsy (FNAB).

Pulsed and power Doppler ultrasound may provide important information about the vascular pattern and the velocimetric parameters. Such information can be useful preoperatively to reach a correct differential diagnosis of malignant or benign thyroid lesion.



Before the advent of fine-needle aspiration biopsy (FNAB), thyroid scintigraphy (or thyroid scanning) performed with technetium Tc 99m pertechnetate (99mTc) or radioactive iodine (I131 or I123) was the initial diagnostic procedure of choice for a thyroid evaluation. The procedure is not as sensitive or specific as FNAB for distinguishing benign nodules from malignant nodules. Iodine-containing compounds and seafood interfere with any tests using radioactive iodine.

Scintigraphic images of the thyroid are acquired 20-40 minutes after intravenous administration of the radionuclide. In more than 90% of cases, clearly benign nodules appear as hot nodules because they are hyperfunctioning and have a high captation rate of radionuclide and, physiologically, of iodine. Malignant nodules usually appear as cold because they are not functioning.

Findings from thyroid scanning are helpful and specific in the preoperative and immediate postoperative periods for localization of cancer or residual thyroid tissue and in observing for tumor recurrence or metastasis. Thyroid scanning can also be useful for diagnosing benign lesions (by FNAB) or solid lesions (by echography).


Fine-Needle Aspiration Biopsy

Fine-needle aspiration biopsy (FNAB) is considered the best first-line diagnostic procedure for a thyroid nodule. FNAB is a safe and minimally invasive procedure.

To perform FNAB, administer local anesthesia at the puncture site, then guide the aspiration biopsy needle (21- or 23-gauge) into the mass. Hold the nodule with the fingers of the left hand while introducing the needle through the skin into the thyroid nodule with the right hand. After aspiration, the material is deposited on a glass slide, fixed with alcohol-acetone, and then stained according to the Papanicolaou test protocol.

The accuracy of FNAB results is better than any other test for detecting papillary thyroid carcinoma. The sensitivity of the procedure is near 80%, the specificity is near 100%, and errors can be diminished using ultrasonographic guidance. False-negative and false-positive results occur less than 6% of the time, as the pathologist may experience difficulty distinguishing some benign cellular adenomas from their malignant counterparts.[35]


Histologic Findings

Papillary thyroid carcinoma usually appears as a grossly firm mass that is irregular and not encapsulated. Microscopically, it is multifocal, and a net invasion of the lymphatics may be demonstrated. Complete or partial papillary architecture with some follicles is present. Otherwise, in some patients, the tumor may lack any papillary pattern.

The thyrocytes are large and show an abnormal nucleus and cytoplasm with several mitoses. In some cases, the thyrocytes may have so-called "Orphan Annie eyes," that is, large round cells with a dense nucleus and clear cytoplasm. Another typical feature of this cancer is the presence of psammoma bodies, probably the remnants of dead papillae.

On immunohistochemistry, papillary thyroid carcinoma usually exhibits the following pattern:

  • Carcinoembryonic antigen (CEA) negative
  • Calcitonin negative
  • Thyroglobulin positive
  • Keratin positive

A study by Liu et al found that when hematoxylin and eosin staining demonstrates loss of cellular polarity/cohesiveness (LOP/C) in the invasive front of papillary thyroid carcinoma, this finding may indicate lymph node metastasis and aggressive clinical behavior of the cancer. LOP/C of 20% or greater correlated significantly with extrathyroid invasion, advanced tumor stage, and recurrence after surgery.[36]

The encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) demonstrates highly indolent behavior. To distinguish this variant from conventional thyroid cancer—and reduce the psychological and clinical consequences associated with the diagnosis of cancer—an international team of thyroid pathologists has recommended reclassifying EFVPTC as "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP).[88]



The staging of well-differentiated thyroid cancers follows the tumor, node, metastasis (TNM) classification system. Staging differs, depending on whether the patient is younger than 45 years of age.

Staging for patients younger than 45 years is as follows:

  • Stage I - Any T, any N, M0 (cancer in thyroid only)
  • Stage II - Any T, any N, M1 (cancer spread cervical lymph nodes or to distant organs)

Staging for patients aged 45 years and older is as follows:

  • Stage I - T1, N0, M0 (cancer only in thyroid, and less than 2 cm)
  • Stage II - T2, N0, M0 and T3, N0, M0 (cancer only in thyroid and between 2-4 cm)
  • Stage III - T4, N0, M0 and any T, N1, M0 (tumor greater than 4 cm or cancer spread outside thyroid but not outside of the central neck compartment)
  • Stage IV - Any T, any N, M1 (cancer spread to either cervical lymph nodes outside of the central neck or distant organs)

See Thyroid Cancer Staging for more information.

Contributor Information and Disclosures

Keith M Baldwin, DO IMPH, Assistant Professor of Surgery, Boston University School of Medicine; Endocrine and Surgical Oncologist, Department of General Surgery, Roger Williams Cancer Center

Keith M Baldwin, DO is a member of the following medical societies: American College of Surgeons, Society of Surgical Oncology, American Association of Endocrine Surgeons, Americas Hepato-Pancreato-Biliary Association, Society of International Humanitarian Surgeons/Surgeons OverSeas (SOS)

Disclosure: Nothing to disclose.


Andrew Scott Kennedy, MD Physician-in-Chief, Radiation Oncology

Andrew Scott Kennedy, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Society for Radiation Oncology, Radiological Society of North America, Americas Hepato-Pancreato-Biliary Association, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jules E Harris, MD, FACP, FRCPC Clinical Professor of Medicine, Section of Hematology/Oncology, University of Arizona College of Medicine, Arizona Cancer Center

Jules E Harris, MD, FACP, FRCPC is a member of the following medical societies: American Association for the Advancement of Science, American Society of Hematology, Central Society for Clinical and Translational Research, American Society of Clinical Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Lodovico Balducci, MD Professor, Oncology Fellowship Director, Department of Internal Medicine, Division of Adult Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida Morsani College of Medicine

Lodovico Balducci, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American College of Physicians, American Geriatrics Society, American Society of Hematology, New York Academy of Sciences, American Society of Clinical Oncology, Southern Society for Clinical Investigation, International Society for Experimental Hematology, American Federation for Clinical Research, American Society of Breast Disease

Disclosure: Nothing to disclose.


Silvia Gagliardi, MD Consulting Staff, Department of Surgery, Medical Center Vita, Italy

Disclosure: Nothing to disclose.

  1. 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 Aug. 40(4):355-64. [Medline].

  2. Wada N, Sugino K, Mimura T, Nagahama M, Kitagawa W, Shibuya H, et al. Treatment Strategy of Papillary Thyroid Carcinoma in Children and Adolescents: Clinical Significance of the Initial Nodal Manifestation. Ann Surg Oncol. 2009 Sep 24. [Medline].

  3. Clayman GL, Shellenberger TD, Ginsberg LE, Edeiken BS, El-Naggar AK, Sellin RV, et al. Approach and safety of comprehensive central compartment dissection in patients with recurrent papillary thyroid carcinoma. Head Neck. 2009 Sep. 31(9):1152-63. [Medline].

  4. Rosenbaum MA, McHenry CR. Contemporary management of papillary carcinoma of the thyroid gland. Expert Rev Anticancer Ther. 2009 Mar. 9(3):317-29. [Medline].

  5. Pelizzo MR, Merante Boschin I, Toniato A, Pagetta C, Casal Ide E, Mian C, et al. Diagnosis, treatment, prognostic factors and long-term outcome in papillary thyroid carcinoma. Minerva Endocrinol. 2008 Dec. 33(4):359-79. [Medline].

  6. [Guideline] AACE/AAES medical/surgical guidelines for clinical practice: management of thyroid carcinoma. American Association of Clinical Endocrinologists. American College of Endocrinology. Endocr Pract. 2001 May-Jun. 7(3):202-20. [Medline]. [Full Text].

  7. [Guideline] NCCN Clinical Practice Guidelines in Oncology. Thyroid carcinoma: Version 1.2016. National Comprehensive Cancer Network. Available at Accessed: September 20, 2016.

  8. Legakis I, Syrigos K. Recent advances in molecular diagnosis of thyroid cancer. J Thyroid Res. 2011. 2011:384213. [Medline]. [Full Text].

  9. Prescott JD, Zeiger MA. The RET oncogene in papillary thyroid carcinoma. Cancer. 2015 Mar 2. [Medline].

  10. Wasenius VM, Hemmer S, Karjalainen-Lindsberg ML, et al. MET receptor tyrosine kinase sequence alterations in differentiated thyroid carcinoma. Am J Surg Pathol. 2005 Apr. 29(4):544-9. [Medline].

  11. Musholt TJ, Musholt PB, Khaladj N, et al. Prognostic significance of RET and NTRK1 rearrangements in sporadic papillary thyroid carcinoma. Surgery. 2000 Dec. 128(6):984-93. [Medline].

  12. 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 Oct 1. 117(19):4390-5. [Medline]. [Full Text].

  13. Xing M, Alzahrani AS, Carson KA, Viola D, Elisei R, et al. Association between BRAF V600E mutation and mortality in patients with papillary thyroid cancer. JAMA. 2013 Apr 10. 309 (14):1493-501. [Medline]. [Full Text].

  14. Li Z, Franklin J, Zelcer S, Sexton T, Husein M. Ultrasound surveillance for thyroid malignancies in survivors of childhood cancer following radiotherapy: a single institutional experience. Thyroid. 2014 Dec. 24 (12):1796-805. [Medline].

  15. Port M, Boltze C, Wang Y, et al. A radiation-induced gene signature distinguishes post-Chernobyl from sporadic papillary thyroid cancers. Radiat Res. 2007 Dec. 168(6):639-49. [Medline].

  16. Ronckers CM, McCarron P, Engels EA, et al. New Malignancies Following Cancer of the Thyroid and Other Endocrine Glands. Curtis RE, Freedman DM, Ron E, Ries LAG, Hacker DG, Edwards BK, Tucker MA, Fraumeni JF Jr. New Malignancies Among Cancer Survivors: SEER Cancer Registries, 1973-2000. No. 05-5302. Bethesda, MD: NIH Publ.; 2006. 375-395. [Full Text].

  17. Williams ED, Abrosimov A, Bogdanova T, Demidchik EP, Ito M, LiVolsi V, et al. Thyroid carcinoma after Chernobyl latent period, morphology and aggressiveness. Br J Cancer. 2004 Jun 1. 90 (11):2219-24. [Medline]. [Full Text].

  18. Negri E, Dal Maso L, Ron E, et al. A pooled analysis of case-control studies of thyroid cancer. II. Menstrual and reproductive factors. Cancer Causes Control. 1999. 10(2):143-155. [Medline].

  19. Franceschi S, Preston-Martin S, Dal Maso L, et al. A pooled analysis of case-control studies of thyroid cancer. IV.Benign thyroid diseases. Cancer Causes Control. 1999. 10(6):583-595. [Medline].

  20. Mack WJ, Preston-Martin S, Dal Maso L, et al. A pooled analysis of case-control studies of thyroid cancer: cigarettesmoking and consumption of alcohol, coffee, and tea. Cancer. 2003. 14(8):773-785. [Medline].

  21. Musholt TJ, Musholt PB, Petrich T, et al. Familial papillary thyroid carcinoma: genetics, criteria for diagnosis, clinical features, and surgical treatment. World J Surg. 2000 Nov. 24(11):1409-17. [Medline].

  22. Hall P, Adami HO. Thyroid Cancer. Adami H, Hunter D, Trichopoulos D, eds. Textbook of Cancer Epidemiology. 2nd ed. New York, NY: Oxford University Press; 2008.

  23. American Cancer Society. Cancer Facts & Figures 2015. American Cancer Society. Available at Accessed: October 8, 2015.

  24. Hay ID, Gonzalez-Losada T, Reinalda MS, Honetschlager JA, Richards ML, Thompson GB. Long-term outcome in 215 children and adolescents with papillary thyroid cancer treated during 1940 through 2008. World J Surg. 2010 Jun. 34(6):1192-202. [Medline].

  25. Yu XM, Wan Y, Sippel RS, Chen H. Should all papillary thyroid microcarcinomas be aggressively treated? An analysis of 18,445 cases. Ann Surg. 2011 Oct. 254(4):653-60. [Medline].

  26. Miyauchi A, Kudo T, Miya A, et al. Prognostic impact of serum thyroglobulin doubling-time under thyrotropin suppression in patients with papillary thyroid carcinoma who underwent total thyroidectomy. Thyroid. 2011 Jul. 21(7):707-16. [Medline].

  27. Rivera M, Tuttle RM, Patel S, Shaha A, Shah JP, Ghossein RA. Encapsulated papillary thyroid carcinoma: a clinico-pathologic study of 106 cases with emphasis on its morphologic subtypes (histologic growth pattern). Thyroid. 2009 Feb. 19(2):119-27. [Medline].

  28. Suman P, Wang CH, Abadin SS, Moo-Young TA, Prinz RA, Winchester DJ. Risk factors for central lymph node metastasis in papillary thyroid carcinoma: A National Cancer Data Base (NCDB) study. Surgery. 2015 Oct 1. [Medline].

  29. Cao J, Chen C, Chen C, Wang QL, Ge MH. Clinicopathological features and prognosis of familial papillary thyroid carcinoma - a large-scale, matched, case-control study. Clin Endocrinol (Oxf). 2015 Jul 20. [Medline].

  30. Bradly DP, Reddy V, Prinz RA, Gattuso P. Incidental papillary carcinoma in patients treated surgically for benign thyroid diseases. Surgery. 2009 Dec. 146(6):1099-104. [Medline].

  31. Kim KW, Park YJ, Kim EH, et al. Elevated risk of papillary thyroid cancer in Korean patients with Hashimoto's thyroiditis. Head Neck. 2011 May. 33(5):691-5. [Medline].

  32. Spencer CA. Clinical review: Clinical utility of thyroglobulin antibody (TgAb) measurements for patients with differentiated thyroid cancers (DTC). J Clin Endocrinol Metab. 2011 Dec. 96(12):3615-27. [Medline].

  33. Segev DL, Umbricht C, Zeiger MA. Molecular pathogenesis of thyroid cancer. Surg Oncol. 2003 Aug. 12(2):69-90. [Medline].

  34. Choi WH, Chung YA, Han EJ, Sohn HS, Lee SH. Clinical value of integrated [18F]fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in the preoperative assessment of papillary thyroid carcinoma: comparison with sonography. J Ultrasound Med. 2011 Sep. 30(9):1267-73. [Medline].

  35. Ng CM, Choi CH, Tiu SC. False-negatives in thyroid nodule aspiration cytology. Hong Kong Med J. 2007 Apr. 13(2):168-9. [Medline].

  36. Liu Z, Kakudo K, Bai Y, et al. Loss of cellular polarity/cohesiveness in the invasive front of papillary thyroid carcinoma, a novel predictor for lymph node metastasis; possible morphological indicator of epithelial mesenchymal transition. J Clin Pathol. 2011 Apr. 64(4):325-9. [Medline].

  37. Chao TC, Lin JD, Chen MF. Gasless video-assisted total thyroidectomy in the treatment of low risk intrathyroid papillary carcinoma. World J Surg. 2004 Sep. 28(9):876-9. [Medline].

  38. Ruggieri M, Straniero A, Pacini FM, et al. Video-assisted surgery of the thyroid diseases. Eur Rev Med Pharmacol Sci. 2003 Jul-Aug. 7(4):91-6. [Medline].

  39. Lee S, Ryu HR, Park JH, et al. Excellence in robotic thyroid surgery: a comparative study of robot-assisted versus conventional endoscopic thyroidectomy in papillary thyroid microcarcinoma patients. Ann Surg. 2011 Jun. 253(6):1060-6. [Medline].

  40. Ywata de Carvalho A, Chulam TC, Kowalski LP. Long-term Results of Observation vs Prophylactic Selective Level VI Neck Dissection for Papillary Thyroid Carcinoma at a Cancer Center. JAMA Otolaryngol Head Neck Surg. 2015 Jul. 141 (7):599-606. [Medline].

  41. Roh JL, Kim JM, Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann Surg Oncol. 2011 Aug. 18(8):2245-50. [Medline].

  42. Popadich A, Levin O, Lee JC, et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery. 2011 Dec. 150(6):1048-57. [Medline].

  43. Yim JH, Kim WB, Kim EY, et al. Adjuvant radioactive therapy after reoperation for locoregionally recurrent papillary thyroid cancer in patients who initially underwent total thyroidectomy and high-dose remnant ablation. J Clin Endocrinol Metab. 2011 Dec. 96(12):3695-700. [Medline].

  44. [Guideline] Sisson JC, Freitas J, McDougall IR, et al. Radiation safety in the treatment of patients with thyroid diseases by radioiodine ¹³¹i: practice recommendations of the american thyroid association. Thyroid. 2011 Apr. 21(4):335-46. [Medline].

  45. Oluwasanjo A, Pathak R, Ukaigwe A, Alese O. Therapy-related acute myeloid leukemia following radioactive iodine treatment for thyroid cancer. Cancer Causes Control. 2015 Oct 9. [Medline].

  46. Heilo A, Sigstad E, Fagerlid KH, et al. Efficacy of ultrasound-guided percutaneous ethanol injection treatment in patients with a limited number of metastatic cervical lymph nodes from papillary thyroid carcinoma. J Clin Endocrinol Metab. 2011 Sep. 96(9):2750-5. [Medline].

  47. [Guideline] Salama JK, Golden DW, Yom SS, Garg MK, Lawson J, McDonald MW, et al. ACR Appropriateness Criteria® thyroid carcinoma. Oral Oncol. 2014 Jun. 50(6):577-86. [Medline].

  48. Perez CA, Santos ES, Arango BA, Raez LE, Cohen EE. Novel molecular targeted therapies for refractory thyroid cancer. Head Neck. 2012 May. 34(5):736-45. [Medline].

  49. Brassard M, Borget I, Edet-Sanson A, et al. Long-term follow-up of patients with papillary and follicular thyroid cancer: a prospective study on 715 patients. J Clin Endocrinol Metab. 2011 May. 96(5):1352-9. [Medline].

  50. Vadiveloo T, Donnan PT, Cochrane L, Leese GP. The Thyroid Epidemiology, Audit, and Research Study (TEARS): morbidity in patients with endogenous subclinical hyperthyroidism. J Clin Endocrinol Metab. 2011 May. 96(5):1344-51. [Medline].

  51. Fatourechi V. Subclinical hypothyroidism: an update for primary care physicians. Mayo Clin Proc. 2009. 84 (1):65-71. [Medline]. [Full Text].

  52. Rugge JB, Bougatsos C, Chou R. Screening for and Treatment of Thyroid Dysfunction: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. 2014 Oct. [Medline]. [Full Text].

  53. [Guideline] Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan. 26 (1):1-133. [Medline]. [Full Text].

  54. [Guideline] Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules: executive summary of recommendations. J Endocrinol Invest. 2010. 33 (5 Suppl):51-6. [Medline]. [Full Text].

  55. Cibas ES, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology. Thyroid. 2009 Nov. 19 (11):1159-65. [Medline].

  56. Baloch ZW, LiVolsi VA. Microcarcinoma of the thyroid. Adv Anat Pathol. 2006 Mar. 13(2):69-75. [Medline].

  57. Burman KD. Micropapillary thyroid cancer: should we aspirate all nodules regardless of size?. J Clin Endocrinol Metab. 2006 Jun. 91(6):2043-6. [Medline].

  58. Clark JR, Lai P, Hall F, et al. Variables predicting distant metastases in thyroid cancer. Laryngoscope. 2005 Apr. 115(4):661-7. [Medline].

  59. Das DK. Age of patients with papillary thyroid carcinoma: is it a key factor in the development of variants?. Gerontology. 2005 May-Jun. 51(3):149-54. [Medline].

  60. Haigh PI, Urbach DR, Rotstein LE. Extent of thyroidectomy is not a major determinant of survival in low- or high-risk papillary thyroid cancer. Ann Surg Oncol. 2005 Jan. 12(1):81-9. [Medline].

  61. Hunt JL, Tometsko M, LiVolsi VA, et al. Molecular evidence of anaplastic transformation in coexisting well-differentiated and anaplastic carcinomas of the thyroid. Am J Surg Pathol. 2003 Dec. 27(12):1559-64. [Medline].

  62. Kim S, Wei JP, Braveman JM, et al. Predicting outcome and directing therapy for papillary thyroid carcinoma. Arch Surg. 2004 Apr. 139(4):390-4; discussion 393-4. [Medline].

  63. Lyshchik A, Drozd V, Demidchik Y, et al. Diagnosis of thyroid cancer in children: value of gray-scale and power doppler US. Radiology. 2005 May. 235(2):604-13. [Medline].

  64. Matsumoto F, Fujii H, Abe M, et al. A novel tumor marker, Niban, is expressed in subsets of thyroid tumors and Hashimoto's thyroiditis. Hum Pathol. 2006 Dec. 37(12):1592-600. [Medline].

  65. Mazzaferri EL, Robbins RJ, Spencer CA, et al. A consensus report of the role of serum thyroglobulin as a monitoring method for low-risk patients with papillary thyroid carcinoma. J Clin Endocrinol Metab. 2003 Apr. 88(4):1433-41. [Medline].

  66. Monchik JM, Donatini G, Iannuccilli J, et al. Radiofrequency ablation and percutaneous ethanol injection treatment for recurrent local and distant well-differentiated thyroid carcinoma. Ann Surg. 2006 Aug. 244(2):296-304. [Medline].

  67. Ohmori N, Miyakawa M, Ohmori K, et al. Ultrasonographic findings of papillary thyroid carcinoma with Hashimoto's thyroiditis. Intern Med. 2007. 46(9):547-50. [Medline].

  68. Ramirez R, Hsu D, Patel A, et al. Over-expression of hepatocyte growth factor/scatter factor (HGF/SF) and the HGF/SF receptor (cMET) are associated with a high risk of metastasis and recurrence for children and young adults with papillary thyroid carcinoma. Clin Endocrinol (Oxf). 2000 Nov. 53(5):635-44. [Medline].

  69. Riesco-Eizaguirre G, Gutierrez-Martinez P, Garca-Cabezas MA, et al. The oncogene BRAF V600E is associated with a high risk of recurrence and less differentiated papillary thyroid carcinoma due to the impairment of Na+/I- targeting to the membrane. Endocr Relat Cancer. 2006 Mar. 13(1):257-69. [Medline].

  70. Roh JL, Park JY, Park CI. Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone. Ann Surg. 2007 Apr. 245(4):604-10. [Medline].

  71. Rosario PW, Fagundes TA, Padrao EL, et al. Total thyroidectomy and lymph node dissection in patients with papillary thyroid carcinoma. Arch Surg. 2004 Dec. 139(12):1385. [Medline].

  72. Shimura H, Haraguchi K, Hiejima Y, et al. Distinct diagnostic criteria for ultrasonographic examination of papillary thyroid carcinoma: a multicenter study. Thyroid. 2005 Mar. 15(3):251-8. [Medline].

  73. Stephens LA, Powell NG, Grubb J, et al. Investigation of loss of heterozygosity and SNP frequencies in the RET gene in papillary thyroid carcinoma. Thyroid. 2005 Feb. 15(2):100-4. [Medline].

  74. Sugitani I, Fujimoto Y, Yamamoto N. Papillary thyroid carcinoma with distant metastases: survival predictors and the importance of local control. Surgery. 2008 Jan. 143(1):35-42. [Medline].

  75. Woodrum DT, Gauger PG. Role of 131I in the treatment of well differentiated thyroid cancer. J Surg Oncol. 2005 Mar 1. 89(3):114-21. [Medline].

  76. Brennan K, Holsinger C, Dosiou C, Sunwoo JB, Akatsu H, Haile R, et al. Development of prognostic signatures for intermediate-risk papillary thyroid cancer. BMC Cancer. 2016 Sep 15. 16 (1):736. [Medline]. [Full Text].

  77. Uchino S, Ishikawa H, Miyauchi A, Hirokawa M, Noguchi S, Ushiama M, et al. Age- and Gender-Specific Risk of Thyroid Cancer in Patients with Familial Adenomatous Polyposis. J Clin Endocrinol Metab. 2016 Sep 13. jc20162043. [Medline].

  78. Liu C, Chen T, Liu Z. Associations between BRAF(V600E) and prognostic factors and poor outcomes in papillary thyroid carcinoma: a meta-analysis. World J Surg Oncol. 2016 Sep 6. 14 (1):241. [Medline]. [Full Text].

  79. Cabrera RN, Chone CT, Zantut-Wittmann DE, Matos PS, Ferreira DM, Pereira PS, et al. The Role of SPECT/CT Lymphoscintigraphy and Radioguided Sentinel Lymph Node Biopsy in Managing Papillary Thyroid Cancer. JAMA Otolaryngol Head Neck Surg. 2016 Sep 1. 142 (9):834-41. [Medline].

  80. Janovsky CC, Maciel RM, Camacho CP, Padovani RP, Nakabashi CC, Yang JH, et al. A Prospective Study Showing an Excellent Response of Patients with Low-Risk Differentiated Thyroid Cancer Who Did Not Undergo Radioiodine Remnant Ablation after Total Thyroidectomy. Eur Thyroid J. 2016 Mar. 5 (1):44-9. [Medline]. [Full Text].

  81. Nikiforov YE, Seethala RR, Tallini G, et al. Nomenclature Revision for Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A Paradigm Shift to Reduce Overtreatment of Indolent Tumors. JAMA Oncol. 2016 Aug 1. 2 (8):1023-9. [Medline].

Standard open thyroidectomy.
Medscape Consult