When you have thyroid cancer, it is important to be treated by doctors with a high level of expertise. MD Anderson has one of the largest thyroid cancer treatment programs in the country, making our physicians some of the most skilled and experienced in the nation.
If you are diagnosed with thyroid cancer, your doctor will discuss the best options to treat it. This depends on several factors, including:
- Type of thyroid cancer
- Size of the cancer
- Your age and health
- Stage of cancer
Thyroid cancer surgery
Most types of thyroid cancer are treated with surgery. Like all surgeries, thyroid cancer surgery is most successful when performed by a specialist with a great deal of experience in the particular procedure. There are two main types of thyroid cancer surgery:
Total thyroidectomy: During this procedure, the surgeon removes the entire thyroid gland. Lymph nodes in the area of the tumor or in the neck/chest may also be removed. This is a common treatment for all thyroid cancers but less common for anaplastic thyroid cancer. In clinical trials, doctors are exploring surgery for anaplastic thyroid cancer after treatments such as chemotherapy or radiation therapy. People who undergo a total thyroidectomy must take thyroid hormone replacement pills daily for the rest of their lives.
Lobectomy/Hemithyroidectomy: In a lobectomy, only the side of the thyroid where the tumor is located is removed. This type of surgery is usually an option only for small well differentiated thyroid cancers that have not spread.
Radiation therapy for thyroid cancer
New radiation therapy techniques and remarkable skill allow MD Anderson doctors to target tumors more precisely, delivering the maximum amount of radiation with the least damage to healthy cells.
Depending on the type of thyroid cancer and its stage, you may be treated with one of the following types of radiation:
Radioactive iodine for thyroid cancer: Since thyroid cells absorb iodine, patients can be given radioactive iodine to treat their cancer. In these treatments, the patient drinks a liquid or swallows a pill that contains radioactive iodine. The iodine is absorbed by thyroid tissue and destroys cancer cells. This method can be used after a thyroidectomy to kill any remaining thyroid cells. This treatment is not effective for anaplastic or medullary thyroid cancer because those cancer cells do not absorb iodine.
If radioactive iodine is used after surgery, the patient may have to stop taking thyroid hormone pills. This helps stimulate thyroid cells to take up the radioactive iodine.
Women should not become pregnant for one year after radioactive iodine treatment.
External beam radiation: This type of therapy is most effective for thyroid cancers that do not absorb iodine, including anaplastic thyroid cancer. It may be used against thyroid cancer cells remaining after surgery or cancers that are not responding well to other treatments.
Hormone therapy for thyroid cancer
This treatment uses thyroid hormone pills to discourage the growth of cancer cells. In papillary or follicular thyroid cancer, hormone treatment may be used to lower the level of thyroid stimulating hormone (TSH). This hormone could promote the growth of thyroid cancer cells if left unchecked. In other thyroid cancers, hormone therapy may be used to keep thyroid hormone levels normal.
Targeted therapy for thyroid cancer
While many cancer treatments work by directly killing cancer cells, targeted therapy is designed to slow or stop the growth of cancer. It works by interfering with, or targeting, molecules cancer cells use to survive, grow and spread. There are targeted therapies available for all types of thyroid cancer.
Chemotherapy for thyroid cancer
Chemotherapy kills fast growing cells such as cancer cells. It is often used in combination with external beam radiation therapy to treat anaplastic thyroid cancer. Because most other types of thyroid cancer grow slowly, traditional chemotherapy is not typically used for these diseases.
Thyroid cancer clinical trials
As one of the world’s premier cancer centers, MD Anderson participates in many clinical trials (research studies) for thyroid cancer. Sometimes clinical trials are the best option for treatment. Research studies may also help researchers learn how to better treat cancer and improve the future of cancer treatment.
MD Anderson patients have access to clinical trials offering
promising new treatments that cannot be found anywhere else.
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Medullary thyroid cancer is a rare cancer diagnosed in about 1,200 patients annually in the U.S. Because it’s often a silent disease, many patients are diagnosed at an advanced stage.
Recently, there has been tremendous progress made in treating this disease with targeted therapy. We recently spoke with Mimi Hu, M.D., to learn more. She shared some challenges in treating this disease and advances that have been made just this year, including findings from a clinical trial she presented at the European Society for Medical Oncology (ESMO) Virtual Congress 2020 (Abstract 1913O).
What causes medullary thyroid cancer?
Roughly 25% of patients have an inherited mutation in the RET gene, leading to a hereditary syndrome called Multiple Endocrine Neoplasia type 2A (MEN2A) or MEN2B. These are a constellation of other endocrine tumors, including medullary thyroid cancer and pheochromocytoma, an abnormal tumor of the adrenal glands.
With MEN2A, patients have parathyroid enlargement with unregulated parathyroid hormone secretion, causing high calcium and kidney stones and fractures. Patients with MEN2B don't have the parathyroid issue, but they can have these very striking mucosal neuromas or ganglioneuromas in their lips, tongue or other mucosal surfaces.
We don’t really know how the remaining 75% of patients develop it. There is no known risk factor for medullary thyroid cancer, but we do know certain mutations can lead to the cancer developing. In 40% to 50% of patients with non-hereditary medullary thyroid cancer, it will be caused by an acquired RET mutation in the cells that become cancerous. Another 13% to 15% of patients will have an acquired RAS gene mutation, and in the remainder of patients, we have not identified any mutations.
What are common medullary thyroid cancer symptoms?
In many patients, medullary thyroid cancer can be silent for years before it comes to anyone’s attention in a physical exam or with diagnostic imaging studies performed for other reasons.
If there are any symptoms, a patient might experience diarrhea and/or flushing caused by cancer cells producing proteins that stimulate intestinal activity or lead to dilation of the blood vessels.
What is standard therapy for medullary thyroid cancer?
The standard of care is surgery – a total thyroidectomy with removal of the lymph nodes in the region. If the disease has already spread to the lymph nodes, it’s unlikely that a patient will be cured by surgery alone, but surgery is important because we don’t want to risk the disease spreading near the airway or esophagus.
For most patients with medullary thyroid cancer, we follow them over time after surgery by monitoring tumor markers, specifically calcitonin and carcinoembryonic antigen (CEA). If those markers rise, we may perform additional imaging to see if the disease is progressing. If the disease is slow-growing, we don’t offer additional therapy because we don’t have any treatments that can cure patients.
How have targeted therapies improved treatment options for medullary thyroid cancer?
In the early 2000s, we started participating in clinical trials with drugs called tyrosine kinase inhibitors, which block proteins important for the cancer cells to grow and survive. A lot of them were targeting a protein called VEGFR, which is important in angiogenesis, or the formation of new blood vessels. Medullary thyroid cancer relies on that process.
Two of these inhibitors gained approval for medullary thyroid cancer – vandetanib in 2011 and cabozantinib in 2012. This was the result of lots of hard work that we and other cancer centers participated in clinical studies. Although these drugs are not curative, they do result in responses in a significant portion of our patients. But there are a number of side effects associated with these medicines, including diarrhea, high blood pressure, skin peeling, mouth sores, weight loss and wound healing problems, amongst others. Experienced physicians can manage these, but most patients do experience some side effects.
How are new RET inhibitors changing the way we treat medullary thyroid cancer?
It has been exciting to be part of the development of a new generation of targeted therapies that specifically block mutant RET, which is implicated in many medullary thyroid cancers. In collaboration with Vivek Subbiah, M.D., and Maria Cabanillas, M.D., we have enrolled many patients on clinical trials for the RET inhibitors, pralsetinib and selpercatinib. MD Anderson does see a large number of patients with medullary thyroid cancers, and we were major contributors to these clinical studies.
The RET inhibitor selpercatinib was approved by the Food and Drug Administration in May 2020 for both lung cancers with RET alterations, as well as medullary thyroid cancer with activating RET mutations and other thyroid cancers with RET fusions.
What is remarkable with these RET inhibitor drugs is that, in addition to the high percentage of responses we see with both drugs, they have a relatively lower side effect profile and are easier for patients to tolerate. I’ve had many patients see their disease symptoms improve in a matter of days, and patients who were previously on vandetanib or cabozantinib comment on how the side effects are much more bearable.
But RET inhibitors still have side effects. The most common ones are high blood pressure and elevated liver enzymes. We also see low white blood cell levels. It’s important to keep track of lab values for these patients and for them to track their symptoms and blood pressure, but they are overall better tolerated than the prior therapies.
Can you tell us about the latest data on the RET inhibitor pralsetinib?
At the 2020 ESMO Virtual Congress, I presented clinical trial data for the RET inhibitor pralsetinib specifically in patients with RET-mutant medullary thyroid cancer. This was recently approved for RET-altered lung cancer and is under new drug evaluation by the FDA for medullary thyroid cancer.
Overall, we saw very nice responses from patients with medullary thyroid cancer. There was a 60% response rate in patients who previously had been treated with vandetanib or cabozantinib. In patients without prior therapies, there was a 74% response rate. We are still evaluating many patients on this clinical trial, but the majority of patients remained on therapy at one year of treatment.
The side effects are also consistent with what I described earlier: it’s well-tolerated overall.
What’s next for medullary thyroid cancer research?
Although these RET inhibitors are promising, they’re not a magic bullet. Some cancers do progress after therapy. There are a new generation of RET inhibitors in early phase clinical development that may be more effective at treating RET-mutant cancers. We may also consider combining a RET inhibitor with other therapies to target the cancer on multiple fronts. Additionally, we are exploring the possibility of combining other therapies for medullary thyroid cancer.
Of course, not every patient has a RET mutation. We see RAS mutations as I mentioned, and we have a major need for therapies that can target mutant RAS.
Immunotherapy has not shown much promise in treating medullary thyroid cancer either, at least not as a single agent. Perhaps by combining immune checkpoint inhibitors with a targeted therapy we could see benefits, but that needs to be investigated. We also need to continue research to understand mechanisms of resistance to understand what causes patients to progress on therapy.
It’s an exciting time to be a physician in the field of medullary thyroid cancer. Over the last 15 years, we have had an explosion of clinical trials for this very rare cancer. I am very lucky to be a clinician in this environment working to improve care for our patients.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
BY Devon Carter
Hearing you have a thyroid nodule can be scary, but it doesn’t always mean you have cancer. In fact, only about 10% of thyroid nodules are malignant.
But if you’ve been diagnosed with thyroid cancer, you may be feeling anxious about the next steps, which almost always include surgery.
Below, Mark Zafereo, M.D., shares what to consider before undergoing thyroid cancer surgery.
Get an accurate diagnosis
It’s important that you’re comfortable with the evaluation of your thyroid nodule before undergoing surgery. Since most nodules aren’t cancerous, many patients don’t need surgery at all.
There are four types of thyroid cancer. About 95% of thyroid cancers are either papillary thyroid cancer or follicular thyroid cancer. Patients with these cancers typically have a good prognosis.
The remaining 5% are medullary thyroid cancer and anaplastic thyroid cancer, which can be more aggressive and may require more extensive treatment.
There are different types of thyroid cancer surgery
The type of surgery your doctor recommends will be based on a risk assessment that includes the tumor pathology, size and location.
The simplest thyroid tumor surgery is a lobectomy. This procedure removes half the thyroid gland. When a thyroid tumor is more likely to spread, a total thyroidectomy (removal of the entire thyroid gland) may be performed.
If the cancer has spread beyond the thyroid gland to surrounding lymph nodes, a more extensive surgery removing these lymph nodes may be needed.
In rare cases, thyroid cancers may spread to other important structures of the neck, which may require more complex surgeries that are best performed by an expert thyroid and neck surgeon.
Ask the right questions
When you meet with your surgeon, make sure you have a clear understanding of your diagnosis, surgical plan and expected recovery. Here are some questions to ask:
- How many thyroid cancer surgeries do you perform each year? The most experienced thyroid cancer surgeons perform more than 100 thyroid/neck surgeries annually.
- What type of thyroid cancer surgery do I need? How much experience do you have performing this specific type of surgery? If the surgeon hasn’t performed many surgeries like yours, seek a second opinion from someone who has.
- How many of your newly diagnosed patients have to undergo a second thyroid/neck surgery within a year? This number should be less than 1%.
- How closely do you work with an endocrinologist, radiologist and pathologist? It’s important that your doctors collaborate and are all confident in the diagnosis and care plan. This minimizes surprises during and after surgery.
- Will the surgery affect my metabolism regulation? If part of your thyroid gland is removed, it may still produce enough of the hormone that regulates your metabolism. But if you have the whole gland removed, you’ll need to take a daily thyroid hormone pill for the rest of your life.
- What are the risks of this thyroid surgery?
- How much discomfort will I have after surgery?
Every patient’s recovery from thyroid cancer surgery is different
Every patient’s recovery is different. Most people take a week or two off work to recover, but can talk and eat a few hours after surgery. All patients will have a scar after surgery. With surgeries limited to the thyroid, the scar is usually about 2 inches long and will look like a natural crease in the neck over time. But ask your doctor what to expect after your particular surgery.
Don’t rush into surgery
With thyroid cancer, you’re not in a race to remove the tumor as soon as possible. Except for the most aggressive thyroid cancers (such as anaplastic thyroid cancer), these cancers are typically slow-growing. Even when the cancer has spread to the lymph nodes, there’s generally not an urgent need for surgery. So, take time to research your options, and find the right cancer center with the right surgeon to perform the right surgery the first time.
Since there’s more urgency with anaplastic thyroid cancer, we encourage these patients to seek proper care soon after diagnosis. At MD Anderson, our specialized clinic called Facilitating Anaplastic Specialized Treatments, or FAST, enables us to quickly finalize treatment plans for patients with suspected anaplastic thyroid cancer.
Specialized care has benefits
Receiving thyroid cancer care at a major cancer center like MD Anderson can make a significant difference in your outcome. At MD Anderson, we have care teams studying every aspect of thyroid cancer, which gives you access to the most cutting-edge care and clinical trials. In fact, MD Anderson has the most clinical trials in the world for medullary and anaplastic thyroid cancers. No matter what type of thyroid cancer you have, a specialized team can help ensure you have a well-thought-out care plan that reduces your chances of recurrence and the need for another surgery.
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