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Causes and symptoms
- a lump or nodule that can be felt in the neck is the most frequent sign of thyroid cancer
- the lymph nodes may be swollen and the voice may become hoarse because the tumor presses on the nerves leading to the voice box
- some patients experience a tight or full feeling in the neck and have difficulty breathing or swallowing
thyroid cancerA general term for a malignant epithelial lesion of the thyroid with 45,000 new cases/year (US), and 1700 deaths. Women account for three-fourths of cases; current, overall 5-year survival with treatment is 95+%. Carcinoma of the thyroid is divided into histologically—and usually clinically—distinct subtypes in order of increasing aggressiveness: papillary carcinoma, follicular carcinoma, medullary carcinoma, poorly differentiated and undifferentiated (anaplastic) carcinoma.
Palpable neck mass (0.14% of all palpable neck masses ultimately prove to be TC).
Uncertain; the initial (5-year) prognosis depends on the histological subtype, but may recur decades later; administration of TSH stimulates remaining thyroid tissue and prevents symptomatic hypothyroidism, which occurs when thyroid hormone is discontinued, and stimulates radioiodine uptake by residual normal and cancerous thyroid tissue.
Staging, carcinoma of thyroid
pTX—Primary tumour cannot be assessed.
pT0—No evidence of primary tumour.
pT1a— = 10 mm limited to thyroid.
pT1b— = 20 mm, > 10 mm limited to thyroid.
pT2—> 20 mm, ≤ 40 mm limited to thyroid.
pT3—> 40 mm limited to thyroid or any tumour with minimal extrathyroidal extension—e.g. extension to sternothyroid muscles or perithyroid soft tissues.
All anaplastic carcinomas are considered pT4 tumours:
pT4a—Tumour invades beyond thyroid capsule and invades any of: subcutaneous soft tissues, larynx, trachea, oesophagus, recurrent laryngeal nerve.
pT4b—Tumour invades prevertebral fascia, mediastinal vessels or encases carotid artery.
Multifocal tumours (= 2 foci) of all histological types should be designated (m), the largest focus determining the classification—e.g., pT2(m).
pNX—Cannot assess regional lymph nodes.
pN0—No regional nodes involved.
pN1a—Metastasis in level-VI (pretracheal, paratracheal and prelaryngeal/Delphian) lymph nodes.
pN1b—Metastasis in other unilateral, bilateral or contralateral cervical (levels I, II, III, IV or V), or retropharyngeal or superior mediastinal lymph nodes.
M1—Distant metastases proven histologically (MX is not used in TNM v7, which itconsiders as proof that M0 cannot be arrived at by surgical pathology alone).
RX—Cannot assess presence of residual primary tumour.
R0—No residual primary tumour.
R1—Microscopic residual primary tumour.
R2—Macroscopic residual primary tumour.
thyroid cancerThyroid carcinoma Oncology A malignant epithelial lesion of the thyroid that affects 14,000/yr–US, 1100 deaths/yr; ♀ account for 77% of new cases and 61% of deaths; current overall 5-year survival with treatment is 95% Risk factors Persons exposed to the upper body–especially head & neck radiation during childhood; persons with a family Hx of TC or MEN 2 syndrome; the risk of radiation-induced thyroid nodularity and CA ↑ with radiation dose and ↓ the older the person was at the time of irradiation; medullary TC, which comprises about 10% of all TCs, is inherited in 25% of cases as part of MEN 2 syndrome Clinical Palpable neck mass Note 0.14% of palpable neck masses ultimately prove to be TC Management Surgery, radioiodine Prognosis Uncertain; recurrences may occur decades later; administration of TSH stimulates remaining thyroid tissue, and prevents symptomatic hypothyroidism, which occurs when thyroid hormone is discontinued, and stimulates radioiodine uptake by residual thyroid and thyroid CA tissue. See Thyrotropin.
|Mean LOS:||3 days|
|Description:||SURGICAL: Thyroid, Parathyroid, and Thyroglossal Procedures With CC|
|Mean LOS:||4.9 days|
|Description:||MEDICAL: Endocrine Disorders With CC|
Thyroid cancer is the most common endocrine cancer, and the number of new cases in the United States is increasing annually by 3% per 100,000 individuals. The American Cancer Society estimated that in 2013, 60,220 new cases of thyroid cancer were diagnosed: 45,310 in women and 14,910 in men. Most thyroid nodules or tumors develop from thyroid follicular cells; 95% of these nodules and tumors are benign. The remaining 5% of thyroid nodules or tumors are cancerous, and there are several forms of thyroid cancer. Papillary carcinoma is the most common form of primary thyroid cancer. It is also the slowest growing thyroid cancer and is usually multifocal and bilateral in distribution. Papillary carcinoma metastasizes slowly into the cervical lymph nodes and the nodes of the mediastinum and lungs. Follicular cancer is the next most common form. It is more likely to recur than other forms; it generally metastasizes to the regional lymph nodes and is spread by the blood to distant areas such as the bones, liver, and lungs. More than 90% of patients treated for either papillary or follicular carcinoma will live for 15 years or longer after their diagnosis.
Anaplastic carcinoma of the thyroid is a less common form of thyroid cancer and is resistant to both surgical resection and radiation; the 5-year survival rate is between 3% and 17%. Anaplastic cells metastasize quickly, invade the trachea and surrounding tissues, and compress vital structures. Medullary cancer is even less common (3% to 4% of thyroid cancers); it originates in the parafollicular cells of the thyroid. Metastasis occurs to the bones, liver, and kidneys if the disease is not treated. In addition to metastases, other life-threatening complications include compression of surrounding structures (particularly in the neck), leading to difficulty swallowing and breathing. Surgery can cure medullary thyroid cancer; 86% have 5-year survival rate, and 65% survive 10 years or more.
While most individuals with thyroid cancer have no apparent risk factors, the following factors may be involved: family history of goiter, family history of thyroid disease, female gender, and Asian race. People who have been exposed to radiation therapy to the neck are particularly susceptible to thyroid cancer, including those exposed to low-dose radiation as children and others exposed to high-dose radiation for malignancies. About 25% of individuals who had radiation in the 1950s to shrink an enlarged thymus gland, tonsils, or adenoids develop thyroid nodules; approximately 25% of those with nodules actually develop thyroid cancer (6% of those exposed to neck radiation in the first place). Other causes of thyroid cancer include prolonged secretion of thyroid-stimulating hormone (TSH) because of radiation, heredity, or chronic goiter.
Most cases of thyroid cancer are sporadic (75% in a Swedish study and 60% in a French national registry). Rearrangements of the RET or NTRK1 genes to form chimeric oncogenes are observed in about 50% of cases. Familial cases are usually due to the presence of multiple endocrine neoplasia type II (MEN II), a group of autosomal dominantly inherited disorders caused by mutations in the RET oncogene. Familial susceptibility has also been mapped to 19p and 2q21.
Gender, ethnic/racial, and life span considerations
Although benign thyroid nodules and thyroid cancers can occur in people of all ages, those between ages 30 and 50 are most likely to develop papillary and follicular thyroid cancer. Women are three times as likely as men to have thyroid cancer. Ethnicity and race have no known effects on the risk for thyroid cancer.
Global health considerations
Globally, thyroid cancer is more common in females than in males. The incidence of thyroid cancer is approximately 3 per 100,000 females, as compared to 1 per 100,000 males. People in developed nations have two to three times the incidence of thyroid cancer as compared to people in developing nations.
Most patients present with an asymptomatic neck mass. They may also have complaints of neck discomfort, hoarseness, dysphagia (difficulty swallowing), feeling as if they are “breathing through a straw,” and rapid nodule growth. Elicit a family history because some forms of thyroid cancer are inherited. If the thyroid has been completely destroyed by cancer cells, the patient may report a history of sensitivity to cold, weight gain, and apathy from hypothyroidism. If the thyroid has become overstimulated, the patient may describe signs of hyperthyroidism: sensitivity to heat, nervousness, weight loss, and hyperactivity. Changes in thyroid function may also lead to gastrointestinal changes such as diarrhea and anorexia.
The most common symptoms are a palpable thyroid nodule, hoarseness, difficulty swallowing, and neck discomfort. Observe the patient’s neck, noting any mass or enlargement. Patients with anaplastic thyroid cancer may have a rapidly growing tumor that distorts the neck and surrounding structures. Palpate the thyroid gland for size, shape, configuration, consistency, tenderness, and presence of any nodules. Describe the number of nodules present and whether the nodule is smooth or irregular, soft or hard, or fixed to underlying tissue. Note the presence of enlarged cervical lymph nodes, which occurs in 25% of patients with the disease. Auscultation may reveal bruits if the thyroid enlargement results from an increase in TSH, which increases thyroid circulation and vascularity.
Assess the patient’s ability to cope with the sudden illness and the diagnosis of cancer. Determine what a diagnosis of cancer means to the patient. Consider the type of cancer (and the speed of cancer growth) when assessing the patient’s and family’s response to the disease.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Fine-needle aspiration (FNA) biopsy||Microscopic viewing reveals no cancerous cells||Microscopic viewing reveals cancer cells||A thin needle is placed directly into the nodule several times to sample different areas; 5% of FNA biopsies reveal cancer, while 60% to 80% clearly show that the nodule is benign|
|Thyroid scan||Homogenous uptake of radioactive tracer; normal size and shape of thyroid||Abnormal areas of the thyroid may contain less radioactivity (cold nodules with decreased uptake) or more radioactivity (hot nodules with increased uptake)||A small quantity of radioactive iodine is taken orally or intravenously; after the chemicals concentrate in the thyroid, a special camera measures the amount of radiation in the thyroid gland|
|Sentinel lymph node biopsy||Sentinel node (first node into which the tumor drains) is cancer free||Lymph nodes containing cancer will absorb dye and radioactive material||Radioactive tracer and blue dye is injected into tumor and will travel to lymph nodes with cancer; is done to determine if the sentinel node is cancer free|
|Thyroid-stimulating hormone (TSH; thyrotropin)||< 4 mlU/L||Normal or elevated||Used to determine if radioactive iodine will work as therapy|
|Serum calcitonin||< 40 pg/mL||Increased in medullary cancer of thyroid; levels 500 to 2,000 pg/mL are often associated with cancer||Thyroid gland polypeptide hormone produced by thyroid even when no mass is palpable|
Other Tests: Sonogram, computed tomography scan, magnetic resonance imaging, octreotide scan used for determining cancer staging and spread, serum calcium
Primary nursing diagnosis
DiagnosisIneffective airway clearance related to swelling and obstruction
OutcomesRespiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
InterventionsAirway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring
Planning and implementation
Most physicians prescribe surgical treatment of thyroid cancer, with the definitive treatment depending on the size of the nodule. Surgical interventions range from a thyroid lobectomy for cancers smaller than 1 cm that show no signs of metastasis to a total thyroidectomy and, possibly, a modified neck dissection if lymph nodes need to be removed. To prevent complications after the thyroidectomy, careful monitoring for airway obstruction and stridor is essential. A tracheostomy tray should be kept near the patient at all times during the immediate recovery period. In addition, monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased blood pressure, anxiety) and hypocalcemia (tingling of the fingers and toes, carpopedal spasms, and convulsions). The surgical dressing and incision also need to be assessed for excessive drainage or bleeding during the postoperative period. If the patient complains that the dressing feels tight, the surgeon needs to be alerted immediately.
Generally, after surgery is completed, the patient is started on synthetic levothyroxine therapy to suppress TSH levels and establish a euthyroid (normal) state. Most patients do not have chemotherapy or radiotherapy because these modalities are usually ineffective with rapidly growing thyroid cancers. Chemotherapy is usually reserved as an adjuvant measure to halt the spread of metastasis; however, paclitaxel (Taxol) is currently being investigated as a treatment for anaplastic thyroid cancer.
Radioactive iodine (131I) may be used to destroy any remaining thyroid tissue not removed by surgery and to treat affected lymph nodes. For radioiodine therapy to be most effective, patients need to have high serum TSH levels; thus, an intentional hypothyroid condition is induced by stopping thyroid medications for 1 to 2 weeks. This temporary condition causes the pituitary gland to release more TSH.
|Medication or Drug Class||Dosage||Description||Rationale|
|Levothyroxine (Synthroid)||2.6 mcg/kg per day for 7–10 days||Synthetic T4 hormone||Suppresses TSH levels and establishes a euthyroid state postoperatively|
The most important nursing interventions focus on teaching and prevention of complications. When you prepare patients before surgery, discuss not only the procedure and aftercare, but also the methods for postoperative communication such as a magic slate or a point board. Explain that the patient will be able to speak only rarely, will need to rest the voice for several days, and should expect to be hoarse. Answer all questions before surgery. After the procedure, monitor the patient’s ability to speak with each measurement of vital signs. Assess the patient’s voice tone and quality and compare it with the preoperative voice.
Maintaining a patent airway is the most important intervention. Maintain the bed in a high-Fowler position to decrease edema and swelling of the neck. To avoid pressure on the suture line, encourage the patient to avoid neck flexion and extension. Support the head and neck with pillows or sandbags; if the patient needs to be transferred from stretcher to bed, support the head and neck in good body alignment.
Before discharge, make sure the patient has a follow-up appointment for a postdischarge assessment. Make sure the patient has the financial resources to obtain all needed medications; some patients require thyroid supplements for the rest of their lives. Refer the patient or family to the American Cancer Society for additional information.
Evidence-Based Practice and Health Policy
Ward, M.H., Kilfoy, B.A., Weyer, P.J., Anderson, K.E., Folsom, A.R., & Cerhan, J.R. (2010). Nitrate intake and the risk of thyroid cancer and thyroid disease. Epidemiology, 21(3), 389–395.
- Investigators conducted a cohort study among 21,977 women ages 55 to 69 and found that increased dietary nitrate intake was associated with an increased risk of thyroid cancer.
- Compared with women in the lowest quartile of dietary nitrate intake (median, 12.4 mg/day), women in the highest quartile of dietary nitrate intake (median, 53.8 mg/day) were 2.85 times more likely to develop thyroid cancer (95% CI, 1 to 8.11; p = 0.046).
- Higher dietary nitrate was associated with living in a town with a population of more than 10,000 people, more years of education, a higher level of recreational physical activity, and higher intakes of vitamin C and total calories.
- Physical findings: Patency of airway, breathing patterns, voice
- Physical findings of incision: Wound edges, hematoma formation, bleeding, infection
- Presence of complications: Thyrotoxicosis, hypocalcemia, hypothyroidism
- Reaction to diagnosis of thyroid cancer
- Understanding of and interest in cancer support groups
Discharge and home healthcare guidelines
To maintain a euthyroid state, teach the patient and family the symptoms of hypothyroidism for early detection of problems: weakness, fatigue, cold intolerance, weight gain, facial puffiness, periorbital edema, bradycardia, and hypothermia. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Explain that the patient needs routine follow-up laboratory tests to check TSH and thyroxine (T4) levels. Be sure the patient knows when the first postoperative physician’s visit is scheduled. Explain any wound care and that the patient should expect to be hoarse for a week or so after the surgical procedure.