How Should Well Differentiated Thyroid Cancer with Distant Metastatic Disease Be Managed?

  • Tanaz VaghaiwallaEmail author
  • Peter Angelos
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Well differentiated thyroid cancer (WDTC) usually presents with cancer confined to the thyroid gland with or without spread to regional lymph nodes of the central or lateral neck. The patients with thyroid cancer who present with distant metastatic disease have worse outcomes including higher morbidity and mortality. Distant metastatic disease can be divided into metastatic pulmonary disease and metastatic extra-pulmonary disease, which can include primarily skeletal and brain disease. The purpose of this chapter was to review the current recommendations for managing patients with WDTC with distant metastatic disease at initial diagnosis and to present institutional experience. An aggressive management strategy is recommended by national and international guidelines which includes locoregional control with surgical intervention and postoperative radioactive iodine treatment. Institutional practice at our facility is to resect all detectable disease by performing total thyroidectomy and locoregional control with central and lateral neck lymph node dissection when indicated. Surgical resection of distant metastasis is recommended when the lesion is amenable to surgical intervention and when the patient performance status is amenable for undergoing the intervention. Radioactive iodine therapy is recommended for avid lesions, whereas non-avid lesions are a therapeutic dilemma and an area of research interest.


Well differentiated thyroid cancer Thyroid metastases Survival 


  1. 1.
    Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;11:1167–94.CrossRefGoogle Scholar
  2. 2.
    Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;1:1–133.CrossRefGoogle Scholar
  3. 3.
    Mitchell AL, Gandhi A, Scott-Coombes D, Perros P. Management of thyroid cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130:150–60.CrossRefGoogle Scholar
  4. 4.
    Goffredo P, Sosa JA, Roman SA. Differentiated thyroid cancer presenting with distant metastases: a population analysis over two decades. World J Surg. 2013;37:1599–605.CrossRefGoogle Scholar
  5. 5.
    Nixon IJ, Whitcher MM, Palmer FL. The impact of distant metastases at presentation on prognosis in patients with differentiated carcinoma of the thyroid gland. Thyroid. 2012;22:884–9.CrossRefGoogle Scholar
  6. 6.
    Sampson E, Brierly JD, Le LW, Rotstein L, Tsang RW. Clinical management and outcome of papillary and follicular (differentiated) thyroid cancer presenting with distant metastasis at diagnosis. Cancer. 2007;110:1451–6.CrossRefGoogle Scholar
  7. 7.
    Durante C, Haddy E, Leboulleux D, Hartle JP, Travagli B, Caillou M, Ricard JD, Lumbroso F, De Vathaire F, Schlumberger M. Long-term outcome of 444 patients with distant metastases from papillary and follicular thyroid carcinoma: benefits and limits of radioiodine therapy. J Clin Endocrinol Metabol. 2006;91(8):2892–9.CrossRefGoogle Scholar
  8. 8.
    Sabra MM, Ghossein R, Tuttle RM. Time course and predictors of structural disease progression in pulmonary metastases arising from follicular cell-derived thyroid cancer. Thyroid. 2016;26(4):518–24.CrossRefGoogle Scholar
  9. 9.
    Sherman SI. Cytotoxic chemotherapy for differentiated thyroid carcinoma. Clin Oncol. 2010;22(6):464–8.CrossRefGoogle Scholar
  10. 10.
    Brose MS, Nutting CM, Jarzab B, Elisei R, Siena S, Bastholt L, de la Fouchardiere C, Pacini F, Paschke R, Shong YK, Sherman SI, Smit JW, Chung J, Kappeler C, Peña C, Molnár I, Schlumberger MJ, DECISION investigators. Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. Lancet. 2014;384(9940):319–28.CrossRefGoogle Scholar
  11. 11.
    Brose MS, Worden FP, Newbold KL, Guo M, Hurria A. Effect of age on the efficacy and safety of lenvatinib in radioiodine-refractory differentiated thyroid cancer in the Phase III SELECT Trial. J Clin Oncol. 2017;35(23):2692–9.CrossRefGoogle Scholar
  12. 12.
    Bernier MO, Leenhardt L, Hoang C, Aurengo A, Mary JY, Menegaux F, Enkaoua E, Turpin G, Chiras J, Saillant G, Hejblum G. Survival and therapeutic modalities in patients with bone metastases of differentiated thyroid carcinomas. J Clin Endocrinol Metabol. 2001;86:1568–73.CrossRefGoogle Scholar
  13. 13.
    Farooki A, Leung V, Tala H, Tuttle RM. Skeletal-related events due to bone metastases from differentiated thyroid cancer. J Clin Endocrinol Metab. 2012;97(7):2433–9.CrossRefGoogle Scholar
  14. 14.
    Orita Y, Sugitani I, Matsuura M, Ushijima M, Tsukahara K, Fujimoto Y, Kawabata K. Prognostic factors and the therapeutic strategy for patients with bone metastasis from differentiated thyroid carcinoma. Surgery. 2010;147(3):424–31.CrossRefGoogle Scholar
  15. 15.
    McWilliams RR, Giannini C, Hay ID, Atkinson JL, Stafford SL, Buckner JC. Management of brain metastases from thyroid carcinoma: a study of 16 pathologically confirmed cases over 25 years. Cancer. 2003;98(2):356–62.CrossRefGoogle Scholar
  16. 16.
    Hong YW, Lin JD, Yu MC, Hsu CC, Lin YS. Outcomes and prognostic factors in thyroid cancer patients with cranial metastases: a retrospective cohort study of 4,683 patients. Int J Surg. 2018;55:182–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Endocrine Surgery Program, Department of SurgeryThe University of Chicago MedicineChicagoUSA

Personalised recommendations