The thyroid is an endocrine gland located at the base in the middle of the neck, just in front of the trachea. Thyroid cancer in this area may be benign or malignant. The histology of thyroid cancer varies depending on the cell of origin. Papillary and follicular carcinomas are well-differentiated, and arise from the thyroid follicle; medullary carcinomas arise from the supporting C-cells. Poorly-differentiated thyroid cancer (carcinoma) and anaplastic thyroid cancer (carcinoma) are very aggressive variants.

STAFF

At the IEO  thyroid cancer is treated by a multidisciplinary team consisting of specialists in:

• Otolaryngology - Head and Neck Surgery
• Urogenital and Head and Neck Tumors Medical Treatment
• New Drugs and Early Drug Development for Innovative Therapies
• Department of Pathology and Laboratory Medicine
• Department of Medical Imaging and Radiation Sciences

Risk factors of thyroid cancer are ionising radiation on the neck in the past and family history of hereditary thyroid cancer. The presence of pre-existing benign thyroid cancer, hormonal factors, dietary intake of iodine 21 as well as dietary and environmental factors (smoking, solvents, dioxins, viruses) may also be risk factors.

The typical symptoms of thyroid cancer are the single or multiple thyroid nodule accidentally retrieved from the patient himself or displayed in the neck ultrasound performed for other reasons. Other thyroid cancer symptoms may include discomfort when swallowing in the thyroid site or non-specific neck pain.

Based on thyroid cancer symptoms, an early thyroid cancer diagnosis is recommended using ultrasound of the neck, as a very important tool to intercept thyroid cancer in early stage. This makes conservative therapies possible, especially in high-risk patients. Once a suspected thyroid nodule has been located, fine-needle aspiration is carried out under ultrasound guidance in order to define the cytological diagnosis. Blood tests for thyroid function and searching for tumour markers complete the diagnostic process. The treatment of thyroid cancer can be planned according to the results.

Good standards for prevention

• Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
• Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkins, apricots, herbs (probable evidence).
• Keeping a careful eye on oral hygiene.
• Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
• After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
• Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation

THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

 The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life. The cervicofacial surgery program consists of the medical-surgical team, Radiotherapy and Medical Oncology specialists, dedicated radiologists, endocrinologists, nuclear physicians and pathologists. The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

 The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Thyroid cancers

Surgery is the therapy of choice for thyroid cancers, performed by removing part of the gland (hemi-thyroidectomy) or the entire gland (total thyroidectomy), and eventually removing the lymph nodes in the central part of the neck and/or in the lateral loggias according to the stage of the thyroid cancer. Once you know the definitive histological examination of the thyroid cancer, in cases of well-differentiated tumours in advanced stage or with metastases in the cervical lymph nodes, the indication is for radionuclide therapy using iodine 131. Radiotherapy is also indicated in more advanced undifferentiated forms of thyroid cancers that do not respond to other therapies. With complete removal of the gland, replacement therapy with levothyroxine is prescribed from the day following the operation in order to replace the lack of thyroid hormone. 

Innovative and minimally invasive therapies: over the years the Division has developed some original techniques and minimally invasive approaches to improve the oncological and functional results of interventions, so that patients have more therapeutic options with less surgical impact. Some of these therapies are available only here in IEO.

Surgery: our head and neck surgeons perform the highest number of operations for malignant tumours each year than any other center in Italy (AGENAS data). Moreover, for more than 20 years we have been conveying the message of Prof Veronesi, that is, "the minimum effective therapy" also for head and neck lesions. We were the first in Italy to offer conservative thyroid surgery, with over 15 years of experience in hemi-thyroidectomy even for malignant tumours. We were among the first to perform endoscopic conservative surgery of the larynx with over 250 procedures a year, we were pioneers in functional tongue surgery allowing a near normal post-op quality of life. Finally, for over 20 years we have been performing very delicate salivary gland surgery. This is the only recognised head and neck surgery department in Italy.

For 20 years at IEO, hemi-thyroidectomy has been performed in early stage carcinomas retaining half of the thyroid gland, with results on the thyroid cancer equal to those obtained in other centres where the organ is usually completely removed. The use of more advanced equipment such as microscopic goggles and endoscopic optics support surgeons in magnifying the surgical field. Forceps and clotting scissors allow us to minimalise possible complications and to carry out the intervention through small incisions 2cm/3.5 cm MIVAT (Mini-invasive video-assisted thyroidectomy)/MIT (minimally invasive thyroidectomy).

 In recent years at IEO, a surgical technique has been developed using natural dye under ultrasound guidance (USDAS = ultrasound dye-assisted surgery) allowing visualisation of very small pathological structures that are difficult to find (thyroid or disease residues and lymph node metastases) in the neck or in the areas that have already been operated on and characterised by altered anatomy and difficult localisation. At IEO, in cases where the thyroid cancer has progressively developed in districts adjacent to the neck, especially at the level of the mediastinum in sites behind the sternum, surgery is supported by a collaboration between multiple specialists, in particular with thoracic surgeons for a complete multidisciplinary management.

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic district.

Attention to the patient and his quality of life: since 2003, the department has been equipped with a speech therapy service, one of the best in Italy, which deals with the rehabilitation of swallowing, phonation and the articulation of the word. The division also has a dentistry service that deals with the preparation for surgery and postoperative dental rehabilitation. The IEO also has a physiotherapy service for motor and respiratory rehabilitation and a dietician for the management of nutritional aspects.  Pain management and Psychological support services are also offered. A holistic approach which takes care of all the needs of the patient, allowing a more rapid return to normal life.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, prevent dehydration and interruptions of the radio-chemotherapy treatment, reduce the frequency and duration of hospitalisations, and improve the quality of life.

 Adequate nutritional support during radiotherapy treatment can reduce the impact and degree of morbidity (mucositis, odynophagia, dysphagia, xerostomia, dysgeusia, nausea, vomiting, and anorexia), minimise weight loss, preserve the nutritional status, improve the quality of life and optimise by speeding it up the recovery of the patient at the end of treatment.

The use of early and intensive nutritional counseling and oral caloric supplementation have been shown to increase the protein-calorie oral intake, reduce the extent of body weight loss, and reduce the interruptions of the cancer treatment.

In the presence of a sufficiently safe swallowing, oral feeding (using a diet modified in consistency) is the first choice.