Papillary thyroid cancer – diagnosis and treatment

12th June 2025, NIA Diagnostic Imaging

Papillary thyroid carcinoma (PTC) is the most prevalent type of thyroid malignancy, accounting for approximately 75–90% of all thyroid cancer cases (Cozens, 2011; Solbiati et al., 2017). These tumours are typically slow-growing and display distinctive histologic features, including papillary structures, nuclear alterations, and multiple subtypes (Gonzalez-Gonzalez et al., 2011; Limaiem et al., 2023). The prognosis is generally favourable, with survival rates exceeding 90% and low mortality rates, ranging from 4–8% (Cozens, 2011; Solbiati et al., 2017).

PTC is most commonly diagnosed between the third and seventh decades of life, with an average age of diagnosis around 50 years (Solbiati et al., 2017; Limaiem et al., 2023). It occurs more frequently in women, with a female-to-male ratio of approximately 3:1 (Limaiem et al., 2023). A history of ionising radiation exposure is the most significant risk factor (Brito et al., 2016), while other contributing factors include a personal or family history of thyroid disease, obesity, and excessive dietary iodine intake (Limaiem et al., 2023; Ross et al., 2023).

Prognostic outcomes are influenced by several clinical and pathological variables including;

Patient age
Tumour size
Histological subtype
Lymph node involvement
Extrathyroidal extension
Distant metastasis

(Gonzalez-Gonzalez et al., 2011).

SYMPTOMS/PATIENT PRESENTATION

Clinically, PTC often presents as a painless, firm neck nodule, which may be discovered during self-examination, physical evaluation, or incidentally on imaging (Ross et al., 2023). Symptoms such as difficulty swallowing, breathing difficulties, voice changes, or cervical lymphadenopathy may also occur. A hard, fixed thyroid mass with regional lymphadenopathy is strongly suggestive of malignancy (Bailey & Wallwork, 2018).

Epidemiological studies have found that prior benign thyroid conditions—such as thyroiditis, goitre, and nodules—are associated with an increased risk of developing thyroid cancer (Kitahara et al., 2018). While most PTC cases are sporadic, a positive family history accounts for approximately 5–15% of cases (Bailey & Wallwork, 2018; Byun et al., 2020).

THE ROLE OF ULTRASOUND

Ultrasound plays a central role in the detection, risk stratification, and monitoring of thyroid nodules and suspected thyroid malignancies. The American College of Radiology’s Thyroid Imaging Reporting and Data System (ACR TI-RADS) provides a structured and standardised approach for assessing thyroid nodules based on sonographic features. It offers guidance on follow-up imaging and the need for fine- needle aspiration biopsy (American College of Radiology, n.d.).

Ultrasound enables the assessment of key characteristics such as echogenicity, composition, shape, margin definition, and the presence of calcifications—all of which contribute to malignancy risk scoring. Additionally, ultrasound is essential for evaluating cervical lymph nodes and detecting suspicious features such as cystic changes or microcalcifications (Rhys, 2011).

Reviewing previous imaging is crucial to ensure consistency in follow-up and detect interval changes over time (Tamhane & Gharib, 2016). While thyroid-stimulating hormone (TSH) levels are not specific for cancer detection, they help identify underlying benign thyroid disorders such as hypothyroidism or hyperthyroidism (Bailey & Wallwork, 2018). Reviewing prior biopsy results is also critical in guiding management decisions and reducing unnecessary repeat procedures (Bailey & Wallwork, 2018).

Figure 1: Transverse sonogram of a papillary thyroid carcinoma (PTC) (Ghai et al., 2021).

Figure 1 demonstrates a transverse image of the upper pole of the right thyroid lobe of 52-year-old female with a history of multi-nodular goiter (Ghai et al., 2021). In this image, the long white arrow indicates a 6 mm hypoechoic irregular bordered PTC nodule with microcalcifications, and the short white arrow indicates a hypoechoic well-defined benign nodule. (Ghai et al., 2021).

Figure 2: ACR TI-RADS Assessment (American College of Radiology, n. d.).

CONCLUSION

In summary, PTC is a common and treatable thyroid malignancy with a favourable prognosis. Ultrasound is an indispensable imaging modality for its initial evaluation and long-term management. Ultrasound is a safe, cost-effective, and highly sensitive tool for diagnosis, risk assessment, and surveillance of thyroid carcinoma. At NIA Diagnostic Imaging our friendly team are always happy to arrange same- day appointments for thyroid imaging. Proudly, NIA Diagnostic Imaging will also bulk-bill thyroid biopsies for our patients.

References:

American College of Radiology. ( n. d.). ACR TI-RAD. https://www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/TI-RADS Australasian Sonographers Association. (2022). ASA Sonographer Code of Conduct. https://www.sonographers.org/publicassets/0c00c285-1c6f-ea11-90fb-0050568796d8/ASA_Code_of_Conduct_2015.pdf

Bailey, S., & Wallwork, B. (2018). Differentiating between benign and malignant thyroid nodes: an evidence-based approach in general practice. Australian Journal of General Practice, 47(11). doi:10.31128/AJGP-03-18-4518

Brito, J. P., Hay, I. D., & Foote, R. L. (2016). Thyroid cancer. In L. L., Gunderson, & J. E., Tepper (Eds.), Clinical Radiation Oncology (4th ed., pp. 715-730). Elsevier.

Byun, S. -H., Min, C., Choi, H. -G., & Hong, S. -J. (2020). Association between family histories of thyroid cancer and thyroid cancer: A cross-sectional study using the Korean genome and epidemiology study data. Genes, 11(9). doi:10.3390/genes11091039

Cozens, N. (2011). Thyroid and parathyroid. In P. L. Allan, G. M. Baxter, & M. J. Weston (Eds.). Clinical ultrasound (3rd ed., pp. 867- 889). Elsevier.

Ghai, S., O’Brien, C., Goldstein, D. P., & Sawka, A. M. (2021). Ultrasound in active surveillance for low-risk papillary thyroid cancer: imaging considerations in case selection and disease surveillance. Insights into imaging, 12(130). 10.1186/s13244-021-01072-9 Gonzalez-Gonzalez, R., Bologna-Molina, R., Carreon-Burciaga, R. G., Gómezpalacio-Gastelum, M., Molina-Frechero, & Salazar- Rodríguez, S. (2011). Papillary thyroid carcinoma: A differential diagnosis and prognostic values of its different variants: Review of the literature. International Scholarly Research Notices, 2011. doi:10.5402/2011/915925

Kitahara, C. M., Farkas, D. K., Jørgensen, J. O. L., Cronin-Fenton, D., & Sørensen, H. T. (2018). Benign thyroid diseases and risk of thyroid cancer: A nationwide cohort study. The Journal of Clinical Endocrinology and metabolism, 103(6), 2216-2224. doi:10.1210/jc.2017-02599

Limaiem, F., Rehman, A., Anastasopoulou, C., & Mazzoni, T. (2023). Papillary thyroid carcinoma. StatPearls. StatPearls Publishing. Retrieved Aug 10, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK536943/

Ross, J., Parmar H. A., Avram, A., Ibrahim, M., & Mukherji, S. K. (2023). Imaging in thyroid cancer. In P. M., Silverman (Ed.). Oncologic imaging: a multidisciplinary approach (2nd ed., pp. 616-629). Elsevier.

Rhys, R. (2011). Cervical lymph nodes. In P. L. Allan, G. M. Baxter, & M. J. Weston (Eds.). Clinical ultrasound (3rd ed., pp. 920-937). Elsevier.

Solbiati, L., Charboneau, J. W., Cantisani, V., Reading, C., Mauri, G. (2017). The thyroid gland. In C. M. Rumack & D. Levine (Eds.), Diagnostic ultrasound (5th ed., pp. 691-731). Elsevier.

Tamhane, S., & Gharib, H. (2016). Thyroid nodule update on diagnosis and management. Clinical Diabetes and Endocrinology, 2(17). doi: 10.1186/s40842-016-0035-7

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”