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Thyroid cancer remains a significant medical problem in the United States; 12,000 new cases are diagnosed and 1000 deaths are reported each year.
Differentiated thyroid cancer is classified into follicular and papillary (derived from the follicular cells) and medullary thyroid carcinoma (derived from the C cells). Rarely, the thyroid is the site of involvement by lymphoma.
Anaplastic cancer arises from the papillary and follicular cancers. The most common type of thyroid cancer is papillary cancer, which accounts for approximately 70% of all thyroid cancers. It is two to three times more common in females and peaks in the third and fourth decades of life.
Papillary cancer is usually nonencapsulated and sometimes multifocal and tends to spread by the lymphatic route.
Follicular cancer is the second most common form of thyroid cancer, accounting for 15% of all thyroid cancers. It affects a slightly older age group and is more commonly diagnosed in females than in males. Follicular cancer tends to be encapsulated, is usually unifocal, and tends to spread via the hematogenous route; early metastases are seen with small lesions.
Thyroid cancer is now diagnosed at an early stage, and its slow rate of growth makes for a favorable outcome in a majority of cases. Sometimes, however, thyroid tumors are encountered that display aggressive features leading to early death despite aggressive treatment. Moreover, the treatment modalities themselves can sometimes be attended by significant complications, making the optimum treatment of thyroid cancer a highly controversial issue. Therefore, an understanding of the factors that affect prognosis should guide selection of treatment modalities.
In papillary cancer, prognosis is affected by tumor size, presence or absence of metastases, patient age, and degree of differentiation. Generally, the smaller tumors (<1.5>2.5 cm) tend to carry a poorer prognosis. Patient age greater than 40 years at diagnosis tends to carry a poor prognosis in part because of poor concentration of iodine by most tumors. Poorly differentiated tumors tend to run a more aggressive course.
The first line of treatment of thyroid cancer consists of surgical resection. Although the optimum procedure is not known, the more aggressive tumors should be managed with more extensive procedures (near-total or total thyroidectomy with or without lymph node dissection). RAI ablation should be considered when residual or metastatic disease is present. Finally, thyroid hormone treatment should be used with a goal of keeping the TSH level as low as possible without causing overt hyperthyroidism.
RAI ablation and thyroid hormone suppression have been shown to reduce recurrence of thyroid cancer. In this patient, age and tumor size predict a poor outcome. Treatment should, therefore, consist of near-total thyroidectomy, RAI ablation, and thyroid hormone treatment.