Thyroid+Gland

**After a negative FNA radionuclide imaging may be ordered. These nuclear medicine tests utilize I-131, I-125, I-123, or Tc-99. Standard x-rays will show intraglandular calcifiations in thyroid nodes. Blood chemistry to confirm or deny prescence of cancer are T3, T4, TSH, Thyroglobin (3), and serum calcitonin level (for medullary thyroid cancer).4 ** || **Mixed papillary-follicular Ca ** **Hurthle cell oncocytic Ca: ** **Medullary thyroid Ca: ** **Anaplastic thyroid Ca: ** **Staging is based upon different histologies and age ** **High-risk factors associated with thyroid cancer include [2]:** **Lymph node involvement is not indicative of a prognosis. [2]** || **Stage III papillary and follicular: ** **Stage IV papillary and follicular: ** **Medullary: ** **Anaplastic: **
 * Epidemiology: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">According to Washington & Leaver thyroid cancer is the most common of the endocrine cancers. Comparatively with all cancers it only accounts for approximately 2% of them, thus making thyroid cancer uncommon overall. 1 Papillary and follicular thyroid cancer is more prominent in females than in their male counterparts. There is an increased risk of thyroid cancer in those who have been previously exposed to radiation, and the incidence of thyroid cancer is lower in children and increases with each passing decade with the peak of incidence in persons on their 50’s. Anaplastic and undifferentiated thyroid carcinomas are more prevalent in people later in life.2 ** ||
 * Etiology: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">The causes of thyroid cancers are many. The #1 documented cause of thyroid cancer is related to irradiation of the thyroid prior to the onset of puberty and is usually of a low-grade papillary sub-type. The prevalence of thyroid cancer is shown to be predominant in children whom were afflicted by the nuclear fallouts of Chernobyl and Hiroshima. Those who received radiation therapy for benign conditions such as acne, enlarged thymus gland, and tonsillitis also have shown an increased risk in thyroid cancer. In addition to the aforementioned etiologic factors other factors include nontoxic colloid goiters that are related to papillary and anaplastic thyroid cancers, premalignant adenomas related to follicular thyroid cancer, and genetics relate to medullary thyroid cancer. ** ||
 * Signs & Symptoms: || **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Most patients have a clinical presentation with a palpable mass in the neck. Young people present with palpable enlarged cervical lymph nodes that are indicative of metastasis of thyroid cancer. Due to the indolence of thyroid cancer in general it can go undiagnosed for years. Symptoms of Anaplastic thyroid cancers include hoarseness caused by nerve paralysis, pain, dysphagia and difficulty breathing. Compression of the esophagus and/or airway due to invasion of the tumor may cause these symptoms. 1 **
 * <span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Patients who have been diagnosed with medullary thyroid cancer may present asymptomatically, but may present with systemic symptoms related to vasoactive substances such as cacitonin, which may cause diarrhea. This may indicate a poor prognosis due to advanced disease. 1 ** ||
 * Diagnostic Procedures: || **<span style="color: #632523; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Thyroid nodules are palpable in 3-4% of the U.S. population.3 The majority of such nodules are benign, but a palpable nodule is an indicator for fine needle aspiration and radiographic imaging. Fine needle aspiration (FNA) is the initial diagnositic tool used to discern malignancy. FNA, compared with blood tests and radiographs, has 98% sensitivity, 98% specificity, and 98% accuracy. Results read as BENIGN, SUSPICIOUS, MALIGNANT, or UNSATISFACTORY/INDETERMINANT. A negative FNA still requires careful thought before a repeat FNA or an excisional biopsy is ordered. FNA's best results require at least 3 nodules. **
 * Histology: || **<span style="color: #400000; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Differentiated cancer types ** **<span style="color: #400000; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Papillary thyroid Ca: **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">33-73% of all malignant thyroid tissue **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Slow-growing (3) **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Solid papillary Ca=good prognosis **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Follicular variant Ca=good prognosis **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Diffuse sclerosing, tall cell, columnar cell = poor prognosis **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">age range=30 to 50 yrs old **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">women to men 3:1 incidence4 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Follicular thyroid Ca: **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">14-33% of all malignant thyroid tissue **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Benign; indistinguishable from minimally invasive **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Ca->need FNA for confirmation **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">age range=50-58 yrs old **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">women to men 3:1 incidence4 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">can be benign or malignant **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">cell of origin unclear3 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">5-10% of all malignant thyroid tissue4 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Arises from parafollicular and C cells that produce calcitonin (monitored by checking calcitonin levels) **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Multi-focal or bilateral; @presentation 25% of patients already have palpable lymph nodes **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Mediastinal nodes are often involved5 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">50-75% of patients have +nodes @time of thyroidectomy **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">10% of all malignant thyroid tissue **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">This disease is rare & aggressive3 **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Lesions are large & fixed **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Skin invasion can occur, leading to dermal lymphatic metastases on chest wall & abdominal wall **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">age range=40-90 years **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">no gender preference **
 * **<span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Very poor prognosis **
 * <span style="color: #400000; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">*In 84 cases seen at M.D. Anderson over a 28 year period, only 3 patients had limited disease confined to the thyroid gland without evidence of distant mets.5 ** ||
 * Lymph Node Drainage: || ****<span style="color: #632523; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">First to the central compartment of the thyroid, nodes in the tracheo-esophageal groove, and to the Delphian nodes (anterior to the larynx, just above the isthmus). ******<span style="color: #632523; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Frequently to the cervical nodes, less frequent to anterior mediastinal nodes (except in anaplastic thyroid Ca), occasionally to supraclavicular and retropharyngeal nodes3 ** ||
 * Metastatic Spread: || **<span style="color: #632523; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Distant mets @ presentation is unusual and seen mainly in patients with extracapsular extension, recurrent tumor, or extraglandular extension. Distant mets after treatment occurs in patients with highly invasive lesions.5 ****<span style="color: #632523; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%;">Lung, bone, and liver4 ** ||
 * Grading: || **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">The histologic grade is indicative of the differentiation amongst cells at a tumor site based on how many cells involved in the tumor resemble the initial tissue at the tumor site. [1] Grading is based on a numeric system from Grades 1-4, with the lower the grade, the more differentiated the cells are in the volume. The grading system according to the American Joint Committee on Cancer is: **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">GX: grade cannot be assessed **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">G1: well differentiated **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">G2: moderately differentiated **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">G3: poorly differentiated **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">G4: undifferentiated ** ||
 * Staging: || **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">The American Joint Committee on Cancer staging system is used for thyroid cancer. [2] **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">The "T" stage describes the size of the tumor **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Tx: primary tumor cannot be assessed **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">T0: no evidence of disease **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">T1: tumor is smaller than 1 cm and is limited to the thyroid **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">T2: the tumor is larger than 1 cm but smaller than 4 cm and is still limited to the thyroid **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">T3: the tumor is larger than 4 cm and is still limited to the thyroid **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">T4: a tumor of any size spreading beyond the thyroid **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">The "N" stage describes the lymph node involvement **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Nx: regional lymph nodes cannot be assessed **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">N0: no metastatic spread to regional lymph nodes **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">N1: metastatic spread to lymph nodes **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">N1a: ipsilateral spread to lymph nodes **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">N1b: bilateral, midline, or contralateral spread to lymph nodes **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">The "M" stage describes the metastatic extent of the disease **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Mx: distant metastasis cannot be assessed **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">M0: no distant metastasis **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">M1: distant metastasis **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Papillary or Follicular, less than 45 years of age **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 1: any T, any N, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 2: any T, any N, M1 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 3: N/A **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 4: N/A **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Papillary or Follicular, older than 45 years of age **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 1: T1, N0, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 2: T2, N0, M0 and T3, N0, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 3: T4, N0, M0 and any T, N1, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 4: any T, any N, M1 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Medullary **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 1: T1, N0, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 2: T2, N0, M0 and T3, N0, M0 and T4, N0, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 3: any T, N1, M0 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Stage 4: any T, any M, N1 **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">Undifferentiated **
 * **<span style="color: #008080; font-family: 'Times New Roman',Times,serif;">All undifferentiated or neoplastic histologies are considered Stage 4 ** ||
 * Radiation Side Effects: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Radiation side effects include, but are not limited to:**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Fatigue, headache, nausea, and vomiting within 12 hours**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Swelling and pain of the salivary glands - occurs shortly after Iodine 131 administration**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Hyperthyroidism after treatment**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**Late effects of radiation include pulmonary fibrosis and pneumonitis**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">**2% of patients experience Leukemia as a late effect [2]** ||
 * Prognosis: || <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**The most commonly diagnosed thyroid cancer is papillary cancer, which is one of the most curable cancers that humans can get.[3] Other histologies have worse prognoses, with anaplastic carcinoma having the worst outcome.**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Age - older than age 45 yields worse prognosis**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Hurthlecell histology**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Extension of disease outside of the thyroid**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Tumor sizes larger than 4 cm**
 * <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 120%;">**Distant metastasis**
 * Treatments: || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Stage I and II papillary and follicular: **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Total thyroidectomy followed by I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 ablation (100-149 mCi) **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Lobectomy followed by exogenous thyroid hormone and I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 ablation **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Thyroid stimulating hormone suppression between I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 treatments **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Total thyroidectomy plus removal of involved lymph nodes or other sites of extrathyroid disease **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 ablation for tumors demonstrating uptake of isotope with thyroid stimulating hormone suppression between I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 treatments **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">External-beam radiation therapy (EBRT) if minimal I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 uptake **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 ablation (metastases that demonstrate isotope uptake may be ablated by a therapeutic dose of I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 ) **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">EBRT for localized lesions unresponsive to I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Resection of limited metastases (symptomatic) for tumors with no uptake of I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Thyroid stimulating hormone suppression for lesions unresponsive to I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Thyroidectomy (if M0) with central and bilateral modified neck dissection for clinically palpable mass **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">I<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">131 (taken up by follicular cells and irradiates adjacent C cells)[2] **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">EBRT **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Palliative chemotherapy (various agents) **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Thyroidectomy **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">EBRT **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Chemotherapy (doxorubicin) **

<span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Radiation Therapy Techniques: ** <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Anatomy covered: ** <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Technique: ** <span style="background-color: #ffffff; color: #002060; display: block; font-family: 'Times New Roman',Times,serif; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; vertical-align: auto;">**[3,4]** ||<   || || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">A. Lateral film of upper thyroid treatment field, beam split/IJ used to block bottom portion of field ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">B. Oblique film of lower thyroid treatment field, beam split/IJ used to block upper portion of field. ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">When planning requires a junction through the target volume – use of IJ allows for perfect match line between fields. [5] ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;"> <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 0px; overflow: hidden; text-align: left; text-decoration: none; vertical-align: auto;">﻿ ** <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: baseline;"> ** Figures C & D. Axial and Sagittal Dose Distribution of a thyroid cancer treatment [10] **
 * <span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Dose: **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Carcinomas—70 Gy/7.5 weeks **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Lymphomas---45Gy/4.5-5 weeks **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Off cord at 42-45 Gy **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Entire thyroid tumor or tumor bed **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Adjacent neck tissues **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Superior mediastinum **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">AP/PA with inferior split beam border for matching fields **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Opposed laterals utilizing inferior split beam border for matching AP SCV field **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">Anterior obliques **
 * TD5/5: || <span style="background-color: transparent; color: #000000; display: block; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;"><span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; line-height: normal; margin-bottom: 0pt; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">The TD 5/5 of the thyroid is 45 Gy for all volumes treated which may result in chronic thyroiditis. The TD 5/5’s for the spinal cord resulting in myelitis or necrosis are: **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">47 Gy for 20 cm **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">50 Gy for 10 cm **
 * <span style="background-color: transparent; color: #000000; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">**<span style="background-color: transparent; color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none; vertical-align: auto;">50 Gy for 5 cm **
 * <span style="font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">REFERENCES: **
 * 1) **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Washington, C.M. & Leaver, D. Endocrine System Tumors. In //Principles and Practice of Radiation Therapy.// 3rd ed. St. Louis, MO: Elsevier; 2010:644. **
 * 2) **<span style="color: #7030a0; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Lenhard, R., Osteen, R., & Gansler, T. Cancer of the Thyroid and Parathyroid Glands. In //American Cancer Society’s Clinical Oncology.// Atlanta, GA; 2001: 633-634. **
 * 3) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Hansen. Roach. //Handbook of Evidence-Based Radiation Oncology. 2nd Edition.// New York, NY. Springer. 2010: 177-179 **
 * 4) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Chao. Perez. Brady. //Radiation Oncology Management Decisions. 2nd Edition.// Philadelphia PA. Lippincott Williams & Wilkins. 2002: 295-301 **
 * 5) **<span style="color: #632423; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Million, Cassisi. //Management of Head & Neck Cancer; A Multidisciplinary Approach.// Philadelphia PA. J.B. Lippincott Co. 1994: 789-791 **
 * 6) **<span style="color: #215968; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">American Joint Committee on Cancer. AJCC Cancer Staging Manual. 5th edition. Available at: [] . Accessed on May 31, 2011. **
 * 7) **<span style="color: #215968; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Norman, J. Thyroid Cancer. Endocrineweb website. Available at: [|http://www.endocrineweb.com/conditions/thyroid-cancer/thyroid-cancer] . Accessed on May 31, 2011. **
 * 8) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Thyroid Cancer Treatment (PDQ®). National Cancer Institute Web site. [] Professional. Accessed May 31, 2011. **
 * 9) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Perez C A, Halpern E C, Brady L W, Schmidt-Ullrich R K. Thyroid Cancer. In: //Principles and Practices of Radiation Oncology.// Philadelphia, PA. Lippincott Williams & Wilkins; 2004:1189-1194. **
 * 10) **<span style="color: #002060; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 150%;">Thyroid Cancer. UWLAX Clinical Oncology Class. D2L Web site. Accessed May 30, 2011. **