Thyroid, Papillary Carcinoma, Early Workup

  • Author: Eric J Lentsch, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 3, 2012
 

Laboratory Studies

  • Fine-needle aspiration is one of the mainstays of preoperative diagnosis of papillary carcinoma of the thyroid. The use of fine-needle aspiration cytology can increase the diagnostic accuracy of thyroid malignancy cases to 92%.
  • Serum thyroglobulin level can be used as a postoperative tumor marker for well-differentiated thyroid cancer (ie, papillary, follicular).
  • Two-dimensional gel electrophoresis has also been used as a diagnostic tool to identify tumor-specific proteins from well-differentiated thyroid cancers, but this technique is still being investigated.
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Imaging Studies

  • Ultrasonography: Cervical ultrasonography with fine needle aspiration cytology is the mainstay of the preoperative diagnosis of carcinoma of the thyroid.
  • Iodine-131 scans and CT scans occasionally reveal cold thyroid nodules, requiring a follow up ultrasound and fine-needle aspiration. Similarly,18 F-fluorodeoxyglucose (FDG) avid nodules incidentally found on PET scans are occurring with increasing frequency and may require similar clarification.
  • PET with FDG depicts many malignancies, including thyroid cancers.[6] The role of FDG-PET scanning in differentiated thyroid cancer has been well described.[7] Efforts to distinguish benign from malignant nodules remain controversial, and its expense precludes routine use when malignancy is first diagnosed.[8, 9]
  • Undifferentiated thyroid carcinomas and recurrent or metastatic thyroid cancer my have decreased iodine-131 avidity and consequently present a diagnostic and therapeutic dilemma. In the setting of elevated thyroglobulins and a negative iodine-131 scan, FDG PET/CT offers improved sensitivity, frequently revealing abnormal, FDG avid lesions. Use of FDG-PET/CT during surgical planning for non-iodine avid recurrent disease has been shown significant benefit, especially when ultrasound is equivocal.
  • PET and PET/CT: In addition to data in the literature demonstrating accurate detection of thyroid cancer by PET, one study has hinted that PET may play a role in the management of patients with inconclusive cytologic diagnosis of a thyroid nodule. In this study, PET reduced the number of negative hemithyroidectomies by 66%. Whether the sensitivity of PET and its cost outweighs the costs and risks associated with thyroid surgery have yet to be determined.
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Histologic Findings

See Pathophysiology.

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Staging

Tumor, node, and metastasis (TNM) for papillary carcinoma of the thyroid are classified as follows:

  • Primary tumor (T)
    • TX: Primary tumor cannot be assessed.
    • T0: No evidence of primary tumor is found.
    • T1: Tumor size is 2 cm or less in greatest dimension and is limited to the thyroid.
    • T2: Tumor size is greater than 2 cm but less than 4 cm, and tumor is limited to the thyroid.
    • T3: Tumor size is greater than 4 cm, and tumor is limited to the thyroid or any tumor with minimal extrathyroidal extension (extension to sternothyroid muscle of perithyroid soft tissues).
    • T4a: Tumor extends beyond the thyroid capsule and invades any of the following: subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve.
    • T4b: Tumor invades prevertebral fascia, mediastinal vessels, or encases the carotid artery.
  • Regional lymph nodes (N)
    • NX: Regional nodes cannot be assessed.
    • N0: No regional node metastasis is found.
    • N1a: Metastasis is found in level VI (pretracheal and paratracheal, including prelaryngeal and Delphian) lymph nodes.
    • N1b: Metastasis is found in unilateral, bilateral, or contralateral cervical or upper/superior mediastinal lymph nodes.
  • Distant metastasis (M)
    • MX: Distant metastasis cannot be assessed.
    • M0: No distant metastasis is found.
    • M1: Distant metastasis is present.

Table 1. Stages of Papillary Carcinoma of the Thyroid (Open Table in a new window)

Younger Than 45 YearsAge 45 Years and Older
Stage IAny T, Any N, M0T1, N0, M0
Stage IIAny T, Any N, M1T2, N0, M0
Stage IIIT3, N0, M0, T1, T2, T3, N1a, M0
Stage IVaT1, T2, T3, N1b, M0, T4a, N0, N1, M0
Stage IVbT4b, any N, M0
Stage IVcAny T, any N, M1
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Contributor Information and Disclosures
Author

Eric J Lentsch, MD  Assistant Professor of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

M Boyd Gillespie, MD, MS, FACS  Associate Professor, Department of Otolaryngology, Associate Member of College of Graduate Studies, Medical University of South Carolina; Director, Medical University of South Carolina Snoring Clinics; Surgical Consultant, Medical University of South Carolina Sleep Disorders Center

M Boyd Gillespie, MD, MS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American College of Surgeons, American Head and Neck Society, American Medical Association, Johns Hopkins Medical and Surgical Association, Phi Beta Kappa, and South Carolina Medical Association

Disclosure: Medtronic Consulting fee Consulting; Gyrus Grant/research funds Other; Karl Storz Honoraria None

John C Goddard, MD  Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina

John C Goddard, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Christina ST Wilhoit, MD, EMT, CCRP  Clinical Research Specialist, Head and Neck Tumor Program, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina

Disclosure: Nothing to disclose.

Zoran Rumboldt, MD  Associate Professor, Department of Radiology, Medical University of South Carolina

Zoran Rumboldt, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, and Radiological Society of North America

Disclosure: Siemens Grant/research funds Other

Rana S Hoda, MD, FIAC  Professor of Pathology, Attending Pathologist and Director of Cytopathology, University of Rochester Medical Center

Rana S Hoda, MD, FIAC is a member of the following medical societies: American Society for Clinical Pathology, American Society of Cytopathology, College of American Pathologists, College of American Pathologists, International Academy of Cytology, South Carolina Medical Association, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Allen O Mitchell, MD  Chairman, Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center, Portsmouth

Allen O Mitchell, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Medical Association

Disclosure: Nothing to disclose.

Kenneth M Spicer, MD, PhD  Professor of Radiology with Tenure, Director of Nuclear Medicine Residency, Medical Director of Radiology Informatics, Medical University of South Carolina

Kenneth M Spicer, MD, PhD is a member of the following medical societies: American College of Nuclear Medicine, American College of Nuclear Physicians, American College of Radiology, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

David J Terris, MD, FACS  Porubsky Professor and Chairman, Department of Otolaryngology, Medical College of Georgia

David J Terris, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Association for the Advancement of Science, American Bronchoesophagological Association, American College of Surgeons, American Head and Neck Society, Federation of American Societies for Experimental Biology, International Association of Endocrine Surgeons, Phi Beta Kappa, Radiation Research Society, Society of University Otolaryngologists-Head and Neck Surgeons, and Triological Society

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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

Nader Sadeghi, MD, FRCSC  Professor, Otolaryngology-Head and Neck Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

Nader Sadeghi, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Thyroid Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

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Chief Editor

Arlen D Meyers, MD, MBA  Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Terry A Day, MD; Michael C Noone, MD; Joshua D Hornig, MD, FRCSC; Jyotika K Fernandes, MBBS, MD; and Anand K Sharma, MBBS, to the development and writing of this article.

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Standard open thyroidectomy.
Minimally invasive video-assisted thyroidectomy. Courtesy of Ruggieri et al. BMC Surgery 2005 5:9 doi:10.1186/1471-2482-5-9
Minimally invasive thyroidectomy; identification of the recurrent laryngeal nerve.
Minimally invasive thyroidectomy closure.
Minimally invasive thyroidectomy; division of isthmus and delivery.
Minimally invasive thyroidectomy; incision and exposure.
Minimally invasive thyroidectomy; initial dissection.
Minimally invasive thyroidectomy; superior pole release.
Table 1. Stages of Papillary Carcinoma of the Thyroid
Younger Than 45 YearsAge 45 Years and Older
Stage IAny T, Any N, M0T1, N0, M0
Stage IIAny T, Any N, M1T2, N0, M0
Stage IIIT3, N0, M0, T1, T2, T3, N1a, M0
Stage IVaT1, T2, T3, N1b, M0, T4a, N0, N1, M0
Stage IVbT4b, any N, M0
Stage IVcAny T, any N, M1
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