Medullary thyroid cancer staging

	Medullary thyroid cancer Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ammu Susheela, M.D. [2]

Overview

According to the American Joint Committee on Cancer (AJCC)^[1] there are 4 stages of medullary thyroid cancer based on the clinical features and findings on imaging. Each stage is assigned a letter and a number that designate the tumor size, number of involved lymph node regions, and metastasis.

Staging

**Thyroid TNM staging**
Stage	Description
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, 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 in greatest dimension limited to the thyroid or any tumor with minimal extrathyroid extension (e.g., extension to sternothyroid muscle or perithyroid soft tissues)
T4a	Moderately advanced disease
T4a	Tumor of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, esophagus, or recurrent laryngeal nerve
T4b	Very advanced disease
T4b	Tumor invades prevertebral fascia or encases carotid artery or mediastinal vessel

**Regional Lymph Nodes (N)**
Stage	Description
NX	Regional lymph node cannot be assessed
N0	No regional lymph node metastasis]]
N1	Regional lymph node metastasis
N1a	Metastases to Level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes)
N1b	Metastases to unilateral, bilateral, or contralateral cervical (Levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (Level VII)

**Distant Metastasis (M)**
Stage	Description
M0	No distant metastasis
M1	Distant metastasis

**Anatomic Stage/Prognostic Groups**
Stage	T	N	M
Medullary carcinoma (all age groups)
I	T1	N0	M0
II	T2	N0	M0
T4a	45 YEARS AND OLDER
T4a	I	T1	Any N	M1
II	T2	N0	M0
III	T3	N0	M0
	T1	N1a	M0
	T2	N1a	M0
	T3	N1a	M0
IVA	T4a	N0	M0
	T4a	N1a	M0
	T1	N1b	M0
	T2	N1b	M0
	T3	N1b	M0
	T4a	N1b	M0
IVB	T4b	Any N	M0
Stage IVC	Any T	Any N	M1

Follicular Thyroid Cancer

Stage I Follicular Thyroid Cancer

Stage I follicular carcinoma is localized to the thyroid gland. Follicular thyroid carcinoma must be distinguished from follicular adenomas, which are characterized by their lack of invasion through the capsule into the surrounding thyroid tissue. While follicular cancer has a good prognosis, it is less favorable than that of papillary carcinoma. The 10-year survival is better for patients with follicular carcinoma without vascular invasion than it is for patients with vascular invasion.

Stage II Follicular Thyroid Cancer

Stage II follicular carcinoma is defined as either tumor that has spread distantly in patients younger than 45 years, or tumor that is larger than 2 cm but 4 cm or smaller and is limited to the thyroid gland in patients older than 45 years. The presence of lymph node metastases does not worsen the prognosis among patients younger than 45 years. Follicular thyroid carcinoma must be distinguished from follicular adenomas, which are characterized by their lack of invasion through the capsule into the surrounding thyroid tissue. While follicular cancer has a good prognosis, it is less favorable than that of papillary carcinoma; the 10-year survival is better for patients with follicular carcinoma without vascular invasion than for patients with vascular invasion.

Stage III Follicular Thyroid Cancer

Stage III is follicular carcinoma in patients older than 45 years, larger than 4 cm and limited to the thyroid or with minimal extrathyroid extension, or positive lymph nodes limited to the pretracheal, paratracheal, or prelaryngeal/Delphian nodes. Follicular carcinoma invading cervical tissue has a worse prognosis than tumors confined to the thyroid gland. The presence of vascular invasion is an additional poor prognostic factor. Metastases to lymph nodes do not worsen the prognosis in patients younger than 45 years.

Stage IV Follicular Thyroid Cancer

Stage IV is follicular carcinoma in patients older than 45 years with extension beyond the thyroid capsule to the soft tissues of the neck, cervical lymph node metastases, or distant metastases. The lungs and bone are the most frequent sites of spread. Follicular carcinomas more commonly have blood vessel invasion and tend to metastasize hematogenously to the lungs and to the bone rather than through the lymphatic system. The prognosis for patients with distant metastases is poor.