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Cachectic: Having cachexia, physical wasting with loss of weight and muscle mass due to disease. Patients with advanced cancer, AIDS, severe heart failure and some other major chronic progressive diseases may appear cachectic.

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Papillary Thyroid Cancer

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Thyroid hormone therapy (Levothyroxine)

Levothyroxine

Iodine restricted diet is recommended for 10 to 14 days prior.

Patient need to receive levothyroxine if total thyroidectomy is done.

Used to keep TSH low or normal

Between treatments, suppressive doses of levothyroxine are given to maintain serum TSH levels <0.1 lIU/ml (unless there are specific contraindications)

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Additional Images

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Stage II: In stage II papillary and follicular thyroid cancer, one of the following is found:

·        cancer is found in the thyroid and the tumor is 4 centimeters or smaller; cancer has spread to nearby lymph nodes; or

·        cancer is found in the thyroid, the tumor is larger than 4 centimeters, and cancer may have spread to nearby lymph nodes; or

·        the tumor is any size and cancer has spread from the thyroid to nearby muscles in the neck and may have spread to nearby lymph nodes.

Why patient showing symptoms?

Increase of size of thyroid gland compresses the surrounding structure

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Complication of thyroidectomy

Hemorrhage: severe cases may cause airway compression and be life-threatening

Hypoparathyroidism: results in hypocalcemia which may become symptomatic and life-threatening if unrecognized/untreated. Up to 1/3 of patients undergoing total thyroidectomy will have at least transient hypocalcemia postoperatively. It is important to maintain a consistent protocol for calcium management after total or completion thyroidectomy to minimize related complications.

Injury to the recurrent laryngeal nerve: results in hoarseness and potentially aspiration. This is most commonly temporary but may be permanent <1% of cases.

Injury to the superior laryngeal nerve: results in voice pitch change. Reported rates of injury range from 0% to 58%.

Post-surgical infection: approximately 6% of cases.

Esophageal injury

Tracheal injury

Dysphagia

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Thyroid ultrasonography

- Most commonly used, safe, painless, cost-effective.

Functions:

- Depict internal structure of thyroid gland and its pathology.

- Assess the comparative size of nodules, lymph nodes or goiters in patients.

- Identify the solid component of complex nodule.

- Guide and facilitate fine needle aspiration biopsy of nodule

However, it does not reliably differentiate benign lesions and cancer.

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According to The American Thyroid Association (ATA), thyroid nodule is defined as a discrete lesion within the thyroid gland.

Can be benign or malignant.

Diameter < 1cm : benign

Diameter >2 cm : Increased risk of cancer

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Stage III: In stage III papillary and follicular thyroid cancer, the tumor is any size and cancer has spread from the thyroid to soft tissue under the skin, the esophagus, the trachea, the larynx, or the recurrent laryngeal nerve (a nerve that goes to the larynx). Cancer may have spread to lymph nodes.

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Butterfly-shaped/ H-shaped endocrine gland that situated in the lower part of neck. It consists of two lobes, the right and the left which are joined together by an immediate structure, isthmus.

The lobes are 5 x 2.5 x 2.5 cm in dimension and weigh around 25 gm.

It plays an essential role in regulating the basal metabolic rate (BMR) and stimulates somatic and psychic growth, besides having a vital role in calcium metabolism.

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Why hyperthyroidism leads to muscle wasting?

-        Altered protein and cell turnover rate leads to muscle atrophy

-        Increased lysosomal enzyme activity (cathepsin B and D) caused by thyroid hormone

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Source: CPG Management of Thyroid Disorders

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Pertinent historical factors predicting malignancy include

Young age (<20 years) or old age (>60 years)

Male gender

History of external neck radiation during childhood/adolescence

Rapid growth

Recent changes in speaking, breathing, or swallowing ( / )

Family history of thyroid cancer or MEN type 2

Pertinent physical findings suggesting possible malignancy include:

Firm to hard consistency of nodule ( / )

Irregular shape

Fixation to underlying or overlying tissues ( / )

Vocal cord paralysis ( / )

Suspicious regional lymphadenopathy

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Souce: ATA Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer

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i. TSH level

When the discovery of a thyroid nodule >1cm in any diameter

subnormal: a radionuclide thyroid scan should be obtained to document whether the nodule is hyperfunctioning, isofunctioning, or nonfunctioning

Elevated in patients with nontoxic goitre: suggests the possibility of thyroiditis and hypothyroidism.

In cancer pt: rarely abnormal

ii. Thyroglobulin

increased thyroglobulin levels are found in the following conditions:

1. Untreated and metastatic differentiated thyroid cancers (papillary and follicular; not medullary or anaplastic or other rarer types)

2. Metastases after initial treatment

3. Hyperthyroidism; this is not always correlated with increased thyroxine

4. Subacute thyroiditis

5. Some cases of benign adenoma

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Source: CPG Mangement of Thyroid Disorders

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gold standard for assessing:

nodule/gland size and thyroid parenchyma (homogeneous or heterogeneous),

location and characteristics of any nodule(s)

the presence or absence of suspicious cervical lymph nodes in the central and lateral compartments.

Nodule characteristics: composition  (solid/cystic proportion), echogenicity, shape if taller than wide, margins, and presence of echogenic profile

The pattern of sonographic features associated with a nodule confers a risk of malignancy, and combined with nodule size, guides FNA decision-making

Radiographic Features

cold (hypo-functioning) nodules, but rarely can appear as hot (hyperfunctioning) nodules.

a hypoechoic or isoechoic solid nodule with irregular or poorly defined margins,

micro-calcifications,

taller-than-wide shape,

disorganized internal vascularity.

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Ultrasound of PTC with calcifications and irregular margins

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Ultrasound of PTC with calcifications and irregular margins

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Fine needle aspiration biopsy (FNAB) of thyroid nodules is the main technique for diagnosing thyroid cancer; it has high sensitivity and specificity rates. The technique is easy to perform and safe. It requires an adequate specimen, which should contain at least five or six groups of 10–15 well-preserved cells.

Watch me: https://www.youtube.com/watch?v=QiS7Xxya_2U

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Pathophysiology

- Mutations or rearrangements in the genes specifically encoding for the proteins in the mitogen activated protein kinase called as MAPK pathway are critical to the development and progression of differentiated thyroid cancer.

How does papillary carcinoma occur?

-       In the MAPK pathway, we have the RET gene

-       There will be chromosomal abnormalities (translocation/inversion)

-       If there is a point mutation ret goes towards the medullary carcinoma if there is translocation inversion of the chromosomes it goes towards the papillary carcinoma

-       2nd gene which is mutated very frequently in papillary carcinoma is the BRAF gene

-       Pathogenesis due to the gain of function mutations involving the genes encoding the RET or BRAF

-       RET GENE located on chromosome 10q11 (there is inversion and translocation)

-       This rearrangement will lead to production of a gene which will lead to increase in tyrosine kinase activity.

-       BRAF gene gain of function mutation in this gene, most commonly a valine to glutamate change in codon 600 (brafv600e)

Risk Factors

History of radiation exposure (Ionizing radiation)

Childhood exposure (Low-dose radiation therapy to head and neck for benign diseases)

Environmental exposure (Chernobyl)

Genetics (Family Hx)

Female predominant with a F:M ratio of 3:1

Estrogen considered to be a potential risk factor for papillary thyroid cancer, this justifies the sex difference in the prevalence of thyroid nodules and thyroid cancer (https://pubmed.ncbi.nlm.nih.gov/25052473/)

Commonly occurs around >50 yo (Median age)

White > Blacks

Signs and Symptoms

Presents as painless thyroid nodules

Mass in neck or cervical node

Cold nodules

Hoarseness and dysphagia (20%)

Complication

Extra thyroidal extension

Local or regional recurrences

Distant metastases

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Psammoma body (PB):

a concentric lamellated calcified structure about 50 to 70 μm in size in tumor tissues.

round, microscopic calcifications (collections of calcium salts)

thickening of the basal lamina in some early stages of cancer > thrombosis > calcification > tumor necrosis

detected by biopsy of the mass taken and ultrasound

involved in both cancerous and benign tumors, and can also be a sign of chronic inflammation.

most commonly observed in PTC, meningioma, and papillary serous cystadenocarcinoma of the ovary

In individuals with PTC, detection of psammoma bodies usually means that the individual is more likely to have lymph node metastasis and high-stage cancer when compared to those without PB.

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1.  Non-neoplastic

1. Hyperplastic

2. Colloid

3. Inflammatory

2.  Thyroid cysts

3.  Neoplastic

1. Benign: Follicular adenoma

2. Malignant: Papillary, Follicular, Medullary,  Anaplastic, Lymphoma, Metastasis

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Source: ATA Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer

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Indications

Patients with papillary or follicular thyroid cancer (differentiated thyroid cancer) who had a total thyroidectomy. Appropriate in patients with tumor size more than 2 cm and has one or more risk factors, including obvious extrathyroidal extension, patients more than 45 years of age, lymph node metastases, and distant metastases. RAI therapy is recommended if the tumor is less than 2 cm and there are distant metastases.

MOA

Iodine is a natural precursor for thyroid hormones triiodothyronine (T3) and thyroxine (T4) and is uptaken from the blood into the thyroid follicular cell by the sodium and iodide transporter. Iodine-131 (I-131) exerts its effects once it is taken up by the follicular cells of the thyroid, emitting beta rays that further cause definitive local damage to the thyroid tissue.

Since iodine is absorbed from the gastrointestinal tract and dispersed in the extracellular fluid, most of the absorbed iodine gets concentrated in the thyroid cells with functioning NIS. The thyroid follicular cells absorb iodine through the NIS.This lead to the ability of the well-differentiated thyroid cancer cells to absorb iodine through the sodium-iodide symporter makes RAI an effective treatment for them. If the cancer cells become undifferentiated, they lose the NIS expression, hence cannot take up RAI and do not respond to RAI treatment.

Dose

In patients with a low risk for recurrence, a dose of around 30 mCi can attain adequate ablation. In moderate and high-risk patients, the administered dose has to be escalated accordingly to a maximum of around 250 mCi.

Route of administration

Oral pill (common) or liquid or IV injection

Duration of action- Parameter to stop??
Only one treatment is needed.

sufficient RAI should be administered in a single dose to render the patient hypothyroid

Side effects

Side effects of radioactive iodine treatment are uncommon, but can include:

neck pain or swelling

feeling sick

nausea and vomiting

swelling and tenderness of salivary glands

a dry mouth

an unpleasant taste in the mouth

The treatment does not affect fertility in women. Fertility can be reduced in men after treatment, but it should improve over time.

Why RAI given after surgery?

A course of RAI treatment is often recommended after 6 to 8 weeks of total thyroidectomy. This will help destroy any remaining thyroid cancer cell that is not removed by surgery or treat some types of thyroid cancer that have spread to lymph nodes and other parts of the body. This reduces the risk of the cancer coming back.

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The originating document has been archived. We cannot confirm the completeness, accuracy and currency of the content.

Medically reviewed by Drugs.com. Last updated on Mar 2, 2022.

What do I need to know about cancer pain?

Cancer pain may be short-term or long-term. It may come and go. You may have pain if the tumor damages or blocks tissues, nerves, and blood vessels as it becomes larger. Some cancer cells may produce chemicals that cause pain. Chemotherapy, radiation therapy, or surgery may cause pain. Pain management is an important part of cancer care.

How is cancer pain diagnosed?

A pain diary can help your healthcare provider find the cause of your pain. Include anything that makes your pain better and worse. Also include when your pain begins and ends. Bring the pain diary to follow-up visits with your healthcare provider.

Pain scales help measure the amount of pain you feel. Pain scales may include numbers or faces. Your healthcare provider may ask you to rate the pain on a scale of 0 to 10.

An x-ray, CT, or MRI may be used to find the cause of your cancer pain. You may be given contrast liquid to help the pictures show up better. Tell the healthcare provider if you have ever had an allergic reaction to contrast liquid. Do not enter the MRI room with anything metal. Metal can cause serious injury. Tell the healthcare provider if you have any metal in or on your body.

Stimulation tests may help find nerves or muscles affected by pain. These tests may include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies.

What is nonpharmacologic treatment for cancer pain?

These therapies are used in addition to medicine to decrease or control cancer pain. Talk to your healthcare provider about the right therapy for you:

Heat helps decrease pain and muscle spasms. Apply heat to the area for 20 to 30 minutes every 2 hours for as many days as directed.

Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on the area for 15 to 20 minutes every hour as directed.

Rehabilitation may include physical and occupational therapy. A physical therapist teaches you exercises to help improve movement and strength, and to decrease pain. An occupational therapist teaches you skills to help with your daily activities.

Electrical stimulation uses a device that sends mild and safe electrical signals. These signals decrease your pain when used over a painful body part.

Surgery and other procedures, such as ultrasound, radio waves, thermal (heat), or laser therapy may help relieve your pain. Surgery may include cutting nerves or repairing joints that are the cause of your chronic pain.

What else can I do to help manage my pain?

Aromatherapy is a way of using scents to relax, relieve stress, and decrease pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and trees. They may be inhaled or used during massages, facials, body wraps, and baths.

Biofeedback teaches your body to respond differently to the stress of being in pain. Healthcare providers may use a biofeedback machine to help you know when your body is relaxed.

Meditation: This therapy teaches you how to focus inside yourself. The goal of meditation is to help you feel more calm and peaceful.

Hypnosis is used to put you in a trancelike state and then suggest things that may help you manage pain.

Dietary supplements to ease cancer pain include vitamins, minerals, or herbs. Do not take any vitamins or supplements unless your healthcare provider says it is okay.

Acupuncture therapy uses very thin needles to balance energy channels in the body.

Call 911 for the following:

You have severe chest pain and sudden trouble breathing.

When should I seek immediate care?

You feel so depressed that you cannot cope.

You have problems thinking clearly.

When should I contact my healthcare provider?

Your pain does not get better, or you have new pain.

You still feel anxious or irritable after your therapy.

You have questions or concerns about your condition or care.

Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Medical Disclaimer

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Nonpharmacological Management of Cancer Pain - What You Need to Know

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The originating document has been archived. We cannot confirm the completeness, accuracy and currency of the content. Medically reviewed by Drugs.com. Last updated on Mar 2, 2022. Cancer pain may be short-term or long-term. It may come and go. You may have pain if the tumor damages or blocks tissues, nerves, and blood vessels as it becomes larger.

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Patients receiving RAI need to stay in hospital for a few days afterwards because the iodine will make your body slightly radioactive. Patients will be able to have visitors and go home once the radiation levels in your body have come down.

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Non-pharmacological Tx                      A team of social workers should be appointed to advocate for the quality of life of patients. These palliative team members can focus on multiple domains including the emotional, social, intellectual, and spiritual needs of the patient and family which can often be overlooked. Palliative team members should be experts in the field, trained in managing and mediating issues related to serious illness and end-of-life situations. 

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Non-pharmacological Tx                      A team of social workers should be appointed to advocate for the quality of life of patients. These palliative team members can focus on multiple domains including the emotional, social, intellectual, and spiritual needs of the patient and family which can often be overlooked. Palliative team members should be experts in the field, trained in managing and mediating issues related to serious illness and end-of-life situations. 

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Effect of RAI on hormone?

-        Permanent hypothyroidism (RAI ‘destroys’ thyroid gland, minimising production of thyroid hormone)

-        Doesn’t affect other hormone as only thyroid gland uptake RAI

HRT for TSH suppression post thyroidectomy:

-        Well-differentiated thyroid cancer (papillary and follicular): Dosage is highly individualized as the degree of TSH suppression is initially based on the risk of disease recurrence using a staging system such as the American Thyroid Association (ATA) risk-of-recurrence stratification system . Long-term TSH suppression goals should account for response to therapy, risk of recurrent disease, age, and comorbid conditions .

-        Oral: Initial: 1.6 to 2 mcg/kg/day immediately postsurgery ; adjust dose as needed in 6 weeks based on TSH suppression goals :

-        Note: For patients with ATA low- and intermediate-risk disease whose initial surgery was a lobectomy, some experts initiate therapy at a later time when TSH concentrations or disease status dictate a need .

Management of SE from RAI

No drug for management of SE. Only symptomatic relief/treatment

Short-term side effects of RAI treatment may include:

-        Neck tenderness and swelling

-        Nausea and vomiting

-        Swelling and tenderness of the salivary glands

-        Dry mouth

-        Taste changes

Chewing gum or sucking on hard candy may help with salivary gland problems.

Sialagogue (agent that can increase saliva production) might help in managing dry mouth and taste change

Radioiodine treatment also reduces tear formation in some people, leading to dry eyes. If you wear contact lenses, ask your doctor how long you should keep them out.

Men who receive large total doses of radiation because of many treatments with RAI may have lower sperm counts or, rarely, become infertile. Radioactive iodine may also affect a woman’s ovaries, and some women may have irregular periods for up to a year after treatment. Many doctors recommend that women avoid becoming pregnant for 6 months to a year after treatment. No ill effects have been noted in the children born to parents who received radioactive iodine in the past.

People who have had RAI therapy may have a slightly increased risk of developing leukemia, stomach cancer, and salivary gland cancer in the future. Doctors disagree on exactly how much this risk is increased, but most of the largest studies have found that this is an extremely rare complication.