Thyroid nodule natural history, complications and prognosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The most common diagnoses and their approximate distributions are colloid nodules, cysts, and thyroiditis (in 80 percent of cases); benign follicular neoplasms (in 10 to 15 percent); and thyroid carcinoma (in 5 percent).

Natural History, Complications and Prognosis

Complications

Noncancerous thyroid nodules are not life threatening. Many do not require treatment. Follow-up exams are enough. The outlook for thyroid cancer depends on the type of cancer.

Prognosis

Follicular carcinoma	Minimally invasive follicular thyroid cancer	only invasion of the capsule of the tumor without vascular invasion
	Encapsulated angioinvasive follicular thyroid cancer	minor vascular invasion (≤4 foci of angioinvasion within the tumor or capsule of the tumor) with or without capsular invasion
	Widely invasive follicular thyroid cancer	Extensive invasion of the tumor capsule A multinodular tumor without a well-defined capsule invading the normal thyroid surrounding the tumor Extensive vascular invasion (>4 foci of angioinvasion)

Differentiated and anaplastic thyroid carcinoma TNM staging AJCC UICC 2017

Primary tumor (T)
Papillary, follicular, poorly differentiated, Hurthle cell and anaplastic thyroid carcinoma
T category	T criteria
TX	Primary tumor cannot be assessed
T0	No evidence of primary tumor
T1	Tumor ≤2 cm in greatest dimension limited to the thyroid
T1a	Tumor ≤1 cm in greatest dimension limited to the thyroid
T1b	Tumor >1 cm but ≤2 cm in greatest dimension limited to the thyroid
T2	Tumor >2 cm but ≤4 cm in greatest dimension limited to the thyroid
T3	Tumor >4 cm limited to the thyroid, or gross extrathyroidal extension invading only strap muscles
T3a	Tumor >4 cm limited to the thyroid
T3b	Gross extrathyroidal extension invading only strap muscles (sternohyoid, sternothyroid, thyrohyoid, or omohyoid muscles) from a tumor of any size
T4	Includes gross extrathyroidal extension
T4a	Gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve from a tumor of any size
T4b	Gross extrathyroidal extension invading prevertebral fascia or encasing the carotid artery or mediastinal vessels from a tumor of any size
NOTE: All categories may be subdivided: (s) solitary tumor and (m) multifocal tumor (the largest tumor determines the classification).
Regional lymph nodes (N)
N category	N criteria
NX	Regional lymph nodes cannot be assessed
N0	No evidence of locoregional lymph node metastasis
N0a	One or more cytologically or histologically confirmed benign lymph nodes
N0b	No radiologic or clinical evidence of locoregional lymph node metastasis
N1	Metastasis to regional nodes
N1a	Metastasis to level VI or VII (pretracheal, paratracheal, or prelaryngeal/Delphian, or upper mediastinal) lymph nodes. This can be unilateral or bilateral disease.
N1b	Metastasis to unilateral, bilateral, or contralateral lateral neck lymph nodes (levels I, II, III, IV, or V) or retropharyngeal lymph nodes
Distant metastasis (M)
M category	M criteria
M0	No distant metastasis
M1	Distant metastasis
Prognostic stage groups
Differentiated
When age at diagnosis is...	And T is...	And N is...	And M is...	Then the stage group is...
<55 years	Any T	Any N	M0	I
<55 years	Any T	Any N	M1	II
≥55 years	T1	N0/NX	M0	I
≥55 years	T1	N1	M0	II
≥55 years	T2	N0/NX	M0	I
≥55 years	T2	N1	M0	II
≥55 years	T3a/T3b	Any N	M0	II
≥55 years	T4a	Any N	M0	III
≥55 years	T4b	Any N	M0	IVA
≥55 years	Any T	Any N	M1	IVB
Anaplastic
When T is...	And N is...	And M is...	Then the stage group is...
T1-T3a	N0/NX	M0	IVA
T1-T3a	N1	M0	IVB
T3b	Any N	M0	IVB
T4	Any N	M0	IVB
Any T	Any N	M1	IVC

In follicular carcinoma, rates of disease-free patients are 71% at 5 years and 58% at 10 years, and the main predictive factors are presence of local clinical symptoms and infiltration into neighboring structures.

25156926

in one series of patients with papillary thyroid carcinoma who underwent total thyroidectomy, with a median follow-up of 16 years, the cancer-related mortality in patients without metastases at presentation was only 6 percent  7977430

PTC:

Thyroid cancer mortality increases progressively with advancing age, without a specific age cutoff that stratifies mortality risk

Persistent or recurrent disease was associated with nonincidental cancer, lymph node metastases at presentation, or bilateral tumor but not size15292295

The prognosis is poorer in patients who have large tumors 8256208

soft-tissue invasion increases the risk of death fivefold

substantial morbidity if there is involvement of the trachea, esophagus, recurrent laryngeal nerves, or the spinal cord.

The rate of survival in patients with distant metastases is variable, depending upon the site of metastases. Among patients with small pulmonary metastases but no other metastases outside of the neck, the 10-year survival rate is 30 to 50 percent; even higher survival rates have been reported in patients whose pulmonary metastases were detected only by radioiodine imaging8410272

poorer prognosis for specific subtypes of papillary thyroid cancers, including tall cell, insular, and hobnail variants 19956062 17696836

Other factors associated with a minor increase in the risk of either recurrence or death are: 19533244 16030160 ●Multicentricity of intrathyroidal tumor ●Bilateral or mediastinal lymph node involvement ●Greater than 10 nodal metastases ●Nodal metastases with extranodal extension ●Male sex ●Delay in primary surgical therapy of more than one year after detection of a thyroid nodule