Papillary Thyroid cancer

Overview

Thyroid cancer occurs in the cells of the thyroid — a butterfly-shaped gland located at the base of your neck, just below your Adam's apple. Your thyroid produces hormones that regulate your heart rate, blood pressure, body temperature and weight.

Thyroid cancer might not cause any symptoms at first. But as it grows, it can cause pain and swelling in your neck.

Several types of thyroid cancer exist. Some grow very slowly and others can be very aggressive. Most cases of thyroid cancer can be cured with treatment.

Thyroid cancer rates seem to be increasing. Some doctors think this is because new technology is allowing them to find small thyroid cancers that may not have been found in the past.

Signs and Symptoms

Most papillary thyroid cancers do not cause symptoms (i.e. they are asymptomatic). In fact, many patients will not know that they are there. Patients with large nodules may notice a palpable mass (i.e. a mass they can feel) or a visible mass (i.e. a mass they can see). Very large nodules may cause compressive symptoms which include difficulty swallowing, food or pills getting "stuck" when they swallow, and pressure or shortness of breath when lying flat. In cases of advanced cancer that are growing (i.e. invading) into surrounding structures, patients may develop hoarseness or difficulty swallowing. Enlarged neck lymph nodes that are concerning for cancer include those that are non-tender, firm, growing, and/or do not shrink over time. Patients with compressive symptoms, enlarged lymph nodes, hoarseness, and/or a rapidly growing nodule should seek medical evaluation right away.

Diagnosed

Papillary thyroid cancer starts as a growth of abnormal cancer cells within the thyroid. As these cells multiply they form a bump or "nodule" within the thyroid that often sticks out of the side or front of the thyroid gland. For this reason, most papillary thyroid cancers, like all thyroid cancers, are diagnosed after a doctor feels the neck of a patient. Usually the doctor stands behind the patient to feel the thyroid for nodules or bumps. Sometimes, these growths and nodules can be seen when looking at the neck of thin women as a small bump under the skin that moves when the person swallows. Sometimes people are undergoing scans or x-rays of the neck for some other reason and a nodule or worrisome area of the thyroid is seen. Either way, your physician feeling this mass or seeing it as a surprise on some other scan will typically order a thyroid ultrasound to look at the thyroid closely and take pictures of the mass or nodule. If the nodule has some worrisome characteristics the next step is almost always a needle biopsy. We have several pages on needle biopsies of thyroid nodules. If you have recently undergone a thyroid needle biopsy or are scheduled to have a needle biopsy, this page is for you.

Treatment

There are three main parts to the treatment of papillary thyroid cancer:

Surgery:

The best treatment for papillary thyroid cancer is almost always total thyroidectomy (i.e. removal of the entire thyroid). There are a few very specific situations in which some doctors will remove only the half of the thyroid with the cancer (i.e. thyroid lobectomy), but most doctors recommend a total thyroidectomy because:

Most papillary thyroid cancers are multifocal (i.e. in more than one part of the thyroid)

Post-operative RAI ablation therapy is more effective if there is no normal thyroid tissue to soak up the radiation.

Follow-up for recurrence (i.e. cancer that comes back) with the thyroglobulin blood test is more accurate. Thyroglobulin is a protein made by thyroid cells, both cancerous and normal. Without any normal thyroid tissue, the thyroglobulin level should be close to zero and if it rises, then it is likely that the cancer has come back. If there is half of a normal thyroid gland left in place, then the levels are harder to interpret and if the level rises, it will be unclear if the cancer has come back or if the normal thyroid lobe is growing.

The recurrence rate (i.e. chance that cancer comes back) is lower in patients who have had a total thyroidectomy than a lobectomy.

In general, our preference at the Thyroid Center is to remove the entire thyroid gland in order to prevent the cancer from returning or spreading to the opposite side — but the extent of surgery is ultimately up to the patient. Prior to the operation, a lymph node mapping (i.e. an USG exam of the central and lateral compartments of the neck) should be done to see if there are suspicious lymph nodes that may need to be removed along with the thyroid. The most common location to have involved lymph nodes is in the central neck compartment (i.e. the lymph nodes surrounding the thyroid). If there are suspicious looking nodes on lymph node mapping or on inspection in the operating room, a therapeutic central neck dissection (i.e. removal of the central neck lymph nodes) should be performed. Some surgeons suggest removing all of the central neck lymph nodes regardless of whether or not they are suspicious looking in an operation called a prophylactic central neck dissection in order to lower the recurrence rate. However, most surgeons believe that a central neck dissection should only be done if there are suspicious looking lymph nodes because:

The recurrence rate is essentially the same

The complication rate is significantly higher in prophylactic central neck dissections versus therapeutic central neck

Risks of Thyroid Surgery

In the hands of an experienced thyroid surgeon, thyroid surgery is a safe procedure with few complications. The following possible complications are directly related to the operative experience of the surgeon, and these statistics are based on our own results here at Columbia:

Bleeding in the neck:

As with any operation, there is always a chance of bleeding. The average blood loss for this operation is less than a tablespoon and the chance of needing a blood transfusion is extremely rare. However, bleeding in the neck is potentially life-threatening because as the blood pools, it can push on the windpipe or trachea causing difficulty breathing. Fortunately, in the hands of Columbia Thyroid Center surgeons, the risk of bleeding is less than 1%. Due to this rare risk of bleeding, patients are observed for 4 hours by our highly trained recovery room staff. If there is no sign of bleeding and the patient feels well, he or she may go home. Once at home, patients and their friends/family should watch for signs such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.

Hoarseness (Recurrent laryngeal nerve injury):

There are two nerves called the recurrent laryngeal nerves that run just behind the thyroid. These nerve control the vocal cords. If one of these nerves is injured, the voice may become hoarse. In the hands of our Columbia Thyroid Center surgeons, the chance of having a temporary hoarseness is 3% and the chance of having a permanent hoarseness is less than 1%. Temporary hoarseness usually gets better within a few weeks, but can take up to 6 months to resolve. Even in the rare chance of having a permanently hoarse voice, there are things that can be done to improve or fix the voice.

Hypocalcemia (Hypoparathyroidism):

The parathyroid glands are 4 small, delicate glands each the size of a grain of rice that sit behind the thyroid and control the blood calcium levels. If all 4 glands are injured or removed during the operation, the blood calcium levels can become lower than normal called hypocalcemia. Hypocalcemia can cause symptoms such as numbness and tingling (especially around the lips and in the hands and feet) as well as cramping and even "locking" of the hands and feet. In the hands of Columbia Thyroid Center surgeons, the risk of having a temporarily low blood calcium level is about 5% and the risk of having a permanently low blood calcium level is less than 1%. It is important to note that numbness and tingling may be caused by something other than a parathyroid problem. If a patient has symptoms caused by low blood calcium, the surgeon may prescribe extra calcium and a vitamin D supplement.

Other risks of thyroid surgery include wound infections and seromas. Wound infections happen in about 1 out of 2000 operations (far less than 1%) and because of this low risk, the routine use of antibiotics is not needed. A seroma is a collection of fluid under the incision. Seromas happen rarely and usually disappear within a few weeks. If the seroma is large, the surgeon may drain it with a small needle. The risk of having any of these complications depends on the experience of the surgeon. Although the risk of these complications cannot be eliminated entirely, they can be minimized in the hands of an experienced thyroid surgeon.

Preparing for Surgery

Prior to the operation, patients will need certain pre-operative testing to make sure that they are healthy enough and properly prepared for an operation. The typical recommendations for pre-operative testing include:

Blood tests done within 30 days of the operation

• CBC (complete blood count)
• BMP (basic metabolic profile)
• B-HCG (blood pregnancy test) for menstruating females
• Coagulation profile if the patient is on blood thinners or has a bleeding disorder
• EKG done within 3 months of the operation for patients older than 40

In addition, patients may require additional tests in certain situations to help plan the operation. It is not common to need these additional tests, but they may include:

Fiberoptic laryngoscopy: This test allows the surgeon to look at how well the vocal cords are moving by passing a thin flexible camera through the nose into the airway. This test is used in patients with hoarseness, a previous neck operation, or cases of advanced cancer.

CAT scan of the chest: This test allows the surgeon to evaluate if the thyroid disease is growing down into the chest and if so, how it is affecting the structures in the chest. The CAT scan will also allow the surgeon to see if the trachea is being moved to one side or the other and if it is being narrowed by the thyroid. This test is used in patients with large goiters, substernal goiters, and cases of advanced cancer.

Patients with other significant medical issues may be asked to visit with their medical team to obtain a letter of medical clearance. The medical clearance allows the patient's medical team the opportunity to optimize the patient's health prior to an operation and allow the specialists to make recommendations for how best to care for the patient's other medical issues during the peri-operative period.

Recovery

In general, patients should be eating, drinking, walking around, and doing their normal activities the night of the operation. However, patients will be asked to do no heavy lifting, swimming, or soaking in a bathtub for 1 week after the operation. Patients should call their surgeon's office to make a follow up appointment 3 weeks after surgery.

Pain

Most patients will feel like they have a sore throat for the first few days after the operation, especially when swallowing. Some people experience a dull ache, while others feel a sharp pain. The Thyroid Center recommends taking Tylenol, Motrin, or Advil as the bottle directs around the clock for the first few days (as long as their overall health allows it). The vast majority of patients do not require narcotic pain medications. In general, patient should be able to eat their normal diet, but most patients prefer softer foods for the first few days.

Incision

Your incision is covered with a protective strip of clear glue called collodion. You can shower and wash your hair as usual, but do not soak or scrub the incision. After showering, pat the incision dry. The collodion will turn white and start curling up at the edges in about 5 to 7 days. When this happens, you can trim the edges or let the glue fall off on its own.

If you experience itching once the collodion is off, you may apply lotion to the scar. You might notice bruising around your incision or upper chest and slight swelling above the scar when you are upright. In addition, the scar may become pink and hard. This hardening will peak at about 3 weeks and may result in some tightness especially when swallowing or extending your neck. This will disappear over the next 3 to 6 months.

Bleeding

Bleeding is a rare complication and those few patients who do have a bleeding problem almost always have it during the 4 hour observation period in the recovery room. However, in the first 24 to 48 hours, patients and their family/friends should observe the incision and neck for signs of bleeding in the neck such as difficulty breathing, a high squeaky voice, swelling in the neck that continues to get bigger, and a feeling that something bad is happening. If any of these symptoms happen, the patient should call 911 first and then their surgeon.

Medications

In general, patients may resume taking their normal medications the day after the operation. The exceptions are blood thinners, aspirin, Plavix, and anti-thyroid medications like PTU and Methimazole. Patients should discuss with their doctors when and if they should restart these medications. Typically, patients will be given prescriptions for the following medications after the operation:

Calcium: Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000® tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. After the seventh day, reduce the calcium to one Tums Ultra 1000® tablet three times a day until your follow-up appointment. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000® tablets and if the symptoms do not go away after 30 minutes, call your doctor. We also recommend a multivitamin for most patients.

Patients may also be given a prescription for thyroid hormone medication (Levothyroxine or Synthroid). If the patient was taking thyroid hormone before the operation, they should continue taking the same dose unless it was changed by the surgeon. If the patient was not taking thyroid hormone prior to the operation, the surgeon may prescribe these tablets following surgery. The dose of thyroid hormone is usually based on the person's weight. During the post operative visit, a blood test called TSH level may be checked to measure the levels of thyroid hormone in order to determine if the dose is correct. Thyroid hormone levels will then be measured about every 2 months until the hormone levels are stable (levels generally stabilize in 4 to 5 months).

Voice

Most patients (97%) will not notice any change in their voice after the operation. Rarely, a patient may have temporary changes in the voice such as fluctuations in volume and clarity (hoarseness). In these cases, the voice will often be better in the mornings and "tire" toward the end of the day. Hoarseness generally improves within the first 3 to 4 weeks after the operation but it may take up to 6 months. Patients should not be worried about hurting their voice by talking. If the voice is still hoarse after 3 to 6 months, the surgeon may prescribe voice-strengthening exercises or ask the patient to visit with a voice specialist for evaluation.

Hypocalcemia

In about 5% of patients who have thyroid surgery, the parathyroid glands do not function properly immediately after thyroid surgery. This can also happen after parathyroid surgery. This is the result of the blood calcium level dropping below normal (hypocalcemia) and is usually temporary. Symptoms of hypocalcemia include numbness and tingling in your hands, soles of your feet and around your lips. Some patients experience a "crawling" sensation in the skin, muscle cramps or headaches. These symptoms appear between 24 and 48 hours after surgery. It is rare for them to appear after 72 hours.

Symptoms of hypocalcemia can generally be prevented by taking two Tums Ultra 1000® tablets three times a day for seven days after surgery along with 2000 IU Vitamin D3 daily. After the seventh day, reduce the calcium to one Tums Ultra 1000® tablet three times a day until your follow-up appointment. If symptoms of hypocalcemia develop, take an extra two Tums Ultra 1000® tablets and if the symptoms do not go away after 30 minutes, call your doctor. We also recommend a multivitamin for most patients.