Thyroid cancer and thyroid nodules treatment and progress in Chinese medicine
What is the surgical procedure for thyroid cancer? Should I have a total thyroidectomy or keep part of the thyroid gland? Do I need 131 iodine treatment after surgery? How much Euthyroxine (levothyroxine tablets) should I take? My TSH level is normal, do I need to increase the dosage of the medication? Is a thyroid nodule benign or malignant? Do I need surgery for a thyroid nodule? How many years should I take Chinese medicine? There are so many questions, let’s take a look.
1. Initial treatment of differentiated thyroid cancer
1.1 The fundamental treatment purpose of differentiated thyroid cancer ( 1) to remove the primary foci of tumor, the lesion tissues that spread outside the thyroid envelope and the involved cervical lymph nodes; ( 2) to reduce the disability rate associated with treatment and disease; ( 3) to precisely stage the tumor; ( 4) to facilitate the elective 131 iodine treatment after surgery; ( 5) to facilitate the physician to precisely monitor the recurrence of disease in the long term after surgery; ( 6) to facilitate (6) to control the risk of tumor recurrence and metastasis to a minimum.
1.2 Standard pathological examination shows that 20% to 50% of patients with differentiated thyroid cancer (especially papillary cancer) have lymph node involvement in the neck. Postoperative ultrasonography detects suspicious lymph nodes in the neck in 20% to 31% of patients, and the surgical plan may change accordingly. Unlike other tumors, however, the presence of metastases does not mean that the primary site of differentiated thyroid cancer cannot be removed. However, unlike other tumors, the presence of metastases does not mean that the primary site of differentiated thyroid cancer cannot be removed. Metastases are sensitive to 131 iodine therapy, so even if metastases are present, the primary site of thyroid cancer and its potentially involved tissues should be removed during initial treatment.
The postoperative staging of thyroid cancer can be used to: (1) determine the prognosis of patients with differentiated thyroid cancer; (2) guide the postoperative adjuvant therapy, including 131 iodine therapy and TSH suppression therapy, to reduce the recurrence rate and death rate of patients; (3) determine the timing and frequency of follow-up, and provide more intensive follow-up for high-risk patients.
1.3 Staging
The American Joint Committee on Cancer (AJCC)/International Union Against Cancer (U ICC) classification of thyroid TNM staging
T1 Tumor diameter ≤2 cm
T2 Primary tumor diameter of 2-4 cm
T3 Primary tumor > 4 cm in diameter, confined to the thyroid gland or with a small extension outside the thyroid gland
T4a Tumor spreads beyond the thyroid envelope and invades the subcutaneous soft tissue, larynx, trachea, esophagus or laryngeal nerve
T4b Tumor invades the anterior fascia, wraps around the carotid artery or mediastinal vessels
TX Primary tumor of unknown size, but not extending beyond the thyroid gland
N0 No lymph node metastasis
N1a Tumor metastasis to zone VI [pre-tracheal, paratracheal, and anterior laryngeal (Delphian) lymph nodes
N1b Tumor metastasis to unilateral, bilateral, contralateral cervical or superior mediastinal lymph nodes
NX No intraoperative evaluation of lymph nodes
M0 No distant metastases
M1 with distant metastases
MX No distant metastases evaluated
Staging Patient age < 45 years Patient age ≥ 45 years
Stage I Any T, N, and M0 T1 , N0 , M0
Stage II Any T, N and M1 T2 , N0 , M0
Stage III T3 , N0 , M0 ; T1 , N1a , M0 ; T2 ,
N1a , M0 ; T3 , N1a , M0
Phase ⅣA T4a, N0,M0 ; T4a,N1a,M0 ; T1,N1b,M0 ; T2,N1b,M0 T3,N1b,M0 ;
T4a , N1b , M0
Phase IVB T4b , any N, M0
Stage IVC any T, any N, M1
2. Long-term follow-up of differentiated thyroid cancer
The goal is to closely monitor patients with possible recurrence in order to detect recurrent lesions as early as possible. The content of follow-up varies depending on the persistence of the lesion or the risk of recurrence. The patient’s prognosis and treatment plan should be assessed according to the risk of recurrence.
Low-risk patients: No local or distant metastases after initial surgical treatment and removal of residual lesions, all visible tumors have been removed, no local tissue invasion and no highly invasive pathology or invasion of blood vessels. If 131 I is used, there is no 131 I uptake outside the thyroid bed at the time of the whole body radioiodine scan (RxWBS) after the initial surgery.
Intermediate-risk patients: At the time of the initial surgery, tumor invasion into the parathyroid soft tissue is visible to the naked eye, or the tumor has invasive pathology or invades blood vessels.
High-risk patients: Tumor invasion into peripheral tissues at the time of initial surgery, incomplete tumor resection, distant metastases, or iodine uptake outside the thyroid bed on 131 iodine scan after thyroid remnant removal.
Patients who have undergone total or subtotal thyroidectomy are considered disease-free if all of the following conditions are present: clinical evidence of tumor, no imaging evidence of tumor (no iodine uptake outside the thyroid bed on postoperative whole-body scans, recent diagnostic scans, and neck ultrasound), and in the absence of interfering antibodies, undetectable during suppression and stimulation with TSH In the absence of interfering antibodies, thyroglobulin (Tg) is not detected during TSH suppression or stimulation.
Measurement of serum Tg levels is an important method for monitoring residual or metastatic lesions and is highly sensitive and specific for thyroid cancer, especially after total thyroidectomy and removal of residual lesions. The test is most sensitive after thyroid hormone discontinuation or stimulation with recombinant human thyroid stimulating hormone (rhTSH). Small amounts of residual tumor could not be detected by Tg during TSH suppression with thyroid hormone.
Diagnostic whole-body radioiodine scanning (RxWBS) is the most useful follow-up method when there is no or only a small amount of normal thyroid tissue remaining after treatment. The sensitivity of RxWBS decreases after radioiodine treatment, therefore, low-risk patients without clinical residual tumor foci, undetectable Tg during thyroxine suppression and negative neck ultrasound do not require RxWBS. neck ultrasound is a highly sensitive method to detect neck metastases in patients with differentiated thyroid cancer. Sometimes metastases can be detected by neck ultrasound even before serum Tg is detected under TSH stimulation.
The efficacy of thyrotropin suppression therapy is currently controversial. It has been suggested that thyroid hormone suppression therapy may reduce the incidence of large clinical adverse events during long-term follow-up of thyroid cancer patients, but the optimal level of thyroid suppression with levothyroxine (LT4) is unknown. Sustained TSH suppression (≤0.05 mU/L) resulted in longer recurrence-free survival compared with higher TSH levels (≥1 mU/L). In multivariate analysis, the degree of TSH suppression was an independent predictor of tumor recurrence. In another large study, disease stage, patient age, and 131 iodine treatment were independent predictors of disease prognosis, but not TSH suppression.
If tumor metastases are found during follow-up, 131 iodine therapy is usually not helpful. For tumors invading the upper respiratory and upper gastrointestinal tracts, surgical treatment with adjuvant therapy [131 iodine therapy and/or external beam radiation therapy (EBRT)] is recommended. Patient outcome is determined by complete resection of the tumor and preservation of the patient’s relevant physiological functions, as well as the ability to remove the tumor from the superficially invaded trachea or esophagus. Trachelectomy or pharyngeal esophagectomy is indicated when the tumor invades deeper tissues of the trachea (e.g., directly into the lumen). Less invasive treatment is recommended for patients who cannot be cured, and the use of tracheal stents or tracheotomy may improve the quality of life for such patients. For patients with asphyxia or hemoptysis, laser treatment can be performed prior to radical surgery or palliative care.
Although 131 iodine therapy has been shown to be effective in many patients, the optimal dose of 131 iodine therapy has not yet been determined. 131 iodine therapy can be administered in three ways: (1) empirical fixed-dose therapy; (2) doses determined by blood and body radiation tolerances and the upper limit of radiation tolerance for a specific amount of tumor; (3) in patients with distant metastases or other special circumstances (e.g., renal failure), or in patients who do ( 3) For patients with distant metastases or other special conditions (e.g. renal failure), or those who require rhTSH stimulation, the dose titration method should be used. As the use of radioactive iodine becomes more widespread in the treatment of thyroid cancer, it is important that physicians better understand the long-term risks of radioactive iodine use, such as the effects of the therapy on the salivary glands, the long-term effects on the reproductive system of men and women with curable thyroid cancer, and the risk of secondary diseases such as parotid tumors, gastrointestinal tumors, bladder tumors, and colon cancer after treatment.
The use of rhTSH not only fails to suppress metastases, but may also accelerate the growth of metastases. Without impairing iodine uptake, lithium inhibits iodine release from the thyroid gland, thus contributing to the retention of 131 I in normal thyroid tissue and tumor cells. It has been found that lithium increases the 131 I radiation dose accumulated in tumor metastases by an average of 2-fold, and that tumors release iodine more rapidly.
If Tg is detected without stimulation, or if Tg > 2 ng/ml is stimulated, neck and chest imaging, such as neck ultrasound and thin (5-7 mm) spiral CT of the chest, should be performed to look for tumor metastases. Although intravenous iodine can be helpful in identifying tumor metastases, enhanced scans with iodine should be avoided if radioactive iodine therapy is planned within a few months of the examination. If the scan is negative, surgical treatment may cure the disease, but empirical 131 iodine therapy (100-200 mCi) should also be considered after surgery.
Chemotherapy for patients with advanced iodine-resistant differentiated thyroid cancer has been rarely studied. Moderate doxorubicin (60-75 mg/m2 every 3 weeks) is effective in more than 40% of patients (mostly partially effective or stabilizing), but its duration of action is uncertain.
3.Thyroid nodules
When a thyroid nodule is found, a complete medical history should be taken and a detailed examination of the thyroid gland and adjacent cervical lymph nodes should be performed. History of bone marrow transplantation, head and neck radiation or whole body radiation, family history of thyroid cancer in first-degree relatives, rapid growth of the nodule and hoarseness may indicate a malignant nodule; vocal cord paralysis, enlarged lymph nodes in the neck on the same side of the nodule and relative fixation to the surrounding tissue may also indicate a malignant nodule.
Usually, only nodules >1 cm in diameter should be evaluated, as they may be malignant. Nodules < 1 cm in diameter should also be evaluated when ultrasound findings are suspicious, when the patient has a history of head and neck radiation exposure, or when there is a positive family history of thyroid cancer. Serum thyroid stimulating hormone (TSH) levels should be checked for nodules > 1 cm in diameter. If TSH is low, a radionuclide thyroid scan should be performed to determine whether the nodule is functional, isofunctional (“warm”), or nonfunctional. Functional nodules are rarely malignant, so cytologic evaluation of such nodules is not necessary. If serum TSH is not suppressed, a diagnostic thyroid ultrasound should be performed to help clarify whether there is indeed a nodule consistent with a palpable lesion, whether the cystic portion of the nodule is >50%, and whether the nodule is located posterior to the thyroid. The latter two conditions reduce the accuracy of fine-needle aspiration biopsy (FNA). FNA is recommended even if TSH is elevated because the rate of malignancy of nodules in normal thyroid tissue is similar to that of nodules in tissue involved in Hashimoto’s thyroiditis. Serum thyroglobulin levels are elevated in most thyroid diseases, but this indicator is neither sensitive nor specific for thyroid cancer. Serum calcitonin is a meaningful indicator for the early detection of parathyroid cell hyperplasia and medullary thyroid carcinoma, and a serum calcitonin >100 pg/ml without stimulation is indicative of medullary thyroid carcinoma.
Fine needle aspiration biopsy (FNA) is the most accurate and efficient method for evaluating thyroid nodules. Traditionally, FNA biopsy results have been classified as inconclusive, malignant, indeterminate (or suspicious for neoplasia), or benign. Indeterminate means that the biopsy does not meet the specific diagnostic criteria available and requires additional biopsies under ultrasound guidance. Cystic nodules that are consistently undiagnosed on repeated biopsies based on cytologic findings are likely to be diagnosed as malignant at the time of surgery.
The risk of malignancy in multiple thyroid nodules is the same as in isolated nodules. Ultrasound should be performed to determine the morphology of the multiple nodules, and if only the “dominant” nodule or the largest nodule is biopsied by needle aspiration, thyroid cancer may be missed. If the ultrasound shows a solid nodule with microcalcifications, hypoechogenicity or an abundant blood supply between the nodules, the nodule may be malignant. Patients diagnosed with benign thyroid nodules need to be followed up, as the false negative rate of FNA can be as high as 5%. Benign nodules become smaller in diameter, while malignant nodules increase in size, possibly slowly. Nodule growth itself is not an indication for malignant lesions, but it is an indication for re-biopsy.
4.Progress in Chinese medicine treatment
Papillary adenocarcinoma is the most frequent patient, followed by follicular carcinoma, medullary carcinoma is even less frequent, and undifferentiated carcinoma is the least frequent.
4.1 Views of ancient texts
In Chinese medicine, thyroid cancer is classified as “gall tumor”. In the Song Dynasty, it was classified as “gall tumor”. Chen Wuzhe’s “Three Causes Formula”: “Those with hard and immovable skin are called stone galls, those with unchanging skin color are called flesh galls, those with exposed veins are called tendon galls, those with interlocking red veins are called blood galls, and those that grow with sorrow are called gas galls”. The stone gall is similar to thyroid cancer. The Song Dynasty’s Shengji General Record: “Stone and mud are obtained from the diet of the mountain and water,” the ancients had recognized that the occurrence of galls was related to environmental factors. The ancient people recognized that the occurrence of gall was related to environmental factors. Gall tumor evidence treatment: “Gall tumor, mostly due to uncontrolled joy and anger, excessive worry, and into the disease. The Qi and blood of a person, circulating throughout the body, always want to be free from stagnation, regulation
The lack of proper regulating, qi condensation and blood stagnation, as gall and tumor”. The Treatise on Gall Tumors The treatise on gall tumors says: “The symptoms of the lady’s gall tumor are not Yin and Yang, but are the result of stagnation of blood, turbidity and phlegm in the five viscera”.
The Treatise on Gall Tumors The treatise on Gall Tumor says: “For those who have real qi at the beginning, Hai Zao Yu Hu Tang and Liu Jun Wan; for those who have deficient qi for a long time, Amber Black Dragon Dan and Ten All Flowing Qi Drink are selected and taken, which will naturally shrink and gradually wear off.
4.2 Advantages of Chinese medicine with treatment of thyroid cancer
Generally speaking, Chinese medicine is used to support the righteousness and dispel the evil, that is to say, according to the theory of “deficiency poison causes cancer”, it is used to treat this disease by tonic deficiency and detoxification method.
(1) Post-operative thyroid cancer is treated with TCM to improve clinical symptoms and reduce serum thyroglobulin level: Chinese herbal medicines to benefit Qi and nourish Blood, soften hard nodules and disperse nodules, as well as to activate blood circulation and remove blood stasis have significant effects on post-operative thyroid cancer patients in terms of improving clinical symptoms and reducing serum thyroglobulin level.
(2) To control metastasis of thyroid cancer, reduce metastatic pain, and improve patients’ quality of life.
(3) Softening the raised scar on the neck after thyroid cancer surgery.
(4) Reduce the side effects of chemotherapy for thyroid cancer
The complementary treatment of thyroid cancer with TCM can make up for the shortcomings of surgery, radiation therapy and chemotherapy. After surgery, TCM can prevent recurrence and metastasis and improve patients’ clinical symptoms; after radiotherapy and chemotherapy, TCM can reduce the side effects of radiotherapy and chemotherapy; for those who have metastasis and cannot undergo surgery or radiotherapy or chemotherapy, TCM can be used to regulate the balance of the body’s internal environment and improve the survival rate of patients with cancer.