Papillary Thyroid Carcinoma Workup

  • Author: Luigi Santacroce, MD; Chief Editor: Jules E Harris, MD   more...
 
Updated: Jan 27, 2012
 

Laboratory Studies

The following workup should be considered for patients with papillary carcinoma, a relatively common well-differentiated thyroid cancer:

  • Thyroid function
    • Perform a complete assessment of thyroid function in any patient with thyroid lumps.
    • Not all available 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 indicate thyroid cancer.
    • Evaluate serum levels of thyroglobulin, calcium, and calcitonin.
    • Determining the serum level of carcinoembryonic antigen (CEA) may be helpful (reference range is < 3 ng/dL). However, the implications of the presence of CEA are not specific because 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.
  • TSH suppression test
    • 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 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.
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Imaging Studies

  • Chest radiography, CT scanning, and MRI: These tests are not usually used in the initial workup of a thyroid nodule, except in patients with clear metastatic disease at presentation. These tests are second-level diagnostic tools and are useful in preoperative patient assessment. A study by Choi et al concluded that [18F]fluoro-2-deoxy-D-glucose positron emission tomography/CT did not provide any additional information compared with neck sonography in patients with papillary thyroid carcinoma.[17]
  • Echography
    • This imaging study must be performed first in any patient with possible thyroid malignancy. Echography is noninvasive and inexpensive, and it represents the most sensitive procedure for identifying thyroid lesions and for determining the diameters of a nodule (2-3 mm).
    • Echography is also useful for localizing lesions when a nodule is difficult to palpate or is deeply seated. Echography images can help determine if a lesion is solid or cystic and can help detect the presence of calcifications.
    • The accuracy rate of echography in categorizing nodules as solid, cystic, or mixed is near 90%. It may be used to help direct a fine-needle aspiration biopsy (FNAB).
    • Pulsed and power Doppler echography 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.
  • Scintigraphy
    • Before FNAB, thyroid scintigraphy (or thyroid scanning) performed with technetium Tc 99m pertechnetate (99mTc) or radioactive iodine (iodine I 131 or iodine I 123) 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.
    • The scintigraphy procedure performed with 99mTc has a high error rate because 99mTc is trapped as iodide but is not organified in the thyroid.
    • The 99mTc has a short half-life and cannot help determine the functionality of a thyroid nodule. Radioactive iodine is trapped and organified in the thyroid and can help determine functionality of a thyroid nodule. 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 nodules because they are not functioning.
    • Findings from thyroid scanning are helpful and specific in evaluating 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).
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Other Tests

  • Papillary thyroid cancer is strongly associated with some specific rearrangements of the RET proto-oncogene.[18]
  • If possible, the assessment of the RET proto-oncogene expression should be performed in any people having a relative with a history of papillary thyroid cancer.
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Procedures

  • FNAB is considered the best first-line diagnostic procedure for a thyroid nodule; FNAB is a safe and minimally invasive procedure.
    • Local anesthesia is administered at the puncture site, and the aspiration biopsy needle is guided into the mass. Hold the nodule with the fingers of the left hand while introducing a needle through the skin into the thyroid nodule with the right hand.
    • After aspiration with a needle, 21- or 23-gauge, 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 uninodular lesions. 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.
    • 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.
    • A pathologist may experience difficulty distinguishing some benign cellular adenomas from their malignant counterparts.
  • Perform indirect or fiberoptic laryngoscopy to evaluate airway and vocal cord mobility and to have preoperative documentation of any unrelated abnormalities.
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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 the 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 the psammoma bodies, probably the remnants of dead papillae.

Immunohistochemistry findings usually have a CEA-negative, calcitonin-negative, thyroglobulin-positive, and keratin-positive pattern.

Definitive diagnosis is often not possible with samples obtained from the FNAB because findings cannot accurately distinguish between benign and malignant lesions.

A study by Liu et al found that loss of cellular polarity/cohesiveness (LOP/C) may be a useful morphological feature of epithelial mesenchymal transition under hematoxylin and eosin staining and is an important indicator of lymph node metastasis.[19]

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Staging

The staging of well-differentiated thyroid cancers is related to age for the first and second stages, but it is not related to age for the third and fourth stages. In the staging protocol, T is tumor, N is node, and M is metastasis.

  • Younger than 45 years
    • Stage I - Any T, any N, M0 (cancer in thyroid only)
    • Stage II - Any T, any N, M1 (cancer spread to distant organs)
  • Older than 45 years
    • Stage I - T1, N0, M0 (cancer only in thyroid, may be found in one or both lobes)
    • Stage II - T2, N0, M0 and T3, N0, M0 (cancer only in thyroid and >1.5 cm)
    • Stage III - T4, N0, M0 and any T, N1, M0 (cancer spread outside thyroid but not outside of neck)
    • Stage IV - Any T, any N, M1 (cancer spread to other parts of body)
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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.

Specialty Editor Board

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.

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

Disclosure: Medscape Salary Employment

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, Section of Hematology/Oncology, University of Arizona College of Medicine, 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

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Standard open thyroidectomy.
Table. ACS Estimated New Thyroid Carcinoma Cases and Deaths by Sex, US, 2008[12]
Cases and Deaths Total Males Females
Estimated new cases37,3408,93028,410
Estimated deaths 1,590680910
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