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Thyroid cancer — papillary, follicular, medullary and anaplastic
Differentiated thyroid cancer (papillary and follicular) is treated with surgery, radioactive iodine by risk and TSH suppression; medullary cancer comes from C cells, does not take up iodine and is followed with calcitonin and CEA; anaplastic cancer is an emergency in which BRAF is tested at once.
Why it matters in the exam
The oncology exam asks about calcitonin follow-up after surgery for medullary cancer, a rapidly growing neck mass deviating the trachea, targeted treatment for iodine-refractory tumours, and the link between medullary cancer and the MEN2 syndromes. Distinguishing the four types is the basis of every answer.
Common distractors are giving radioactive iodine in medullary cancer, operating on a patient with MEN2 before excluding phaeochromocytoma, or thinking anaplastic cancer behaves like a differentiated tumour. In differentiated tumours thyroglobulin is the follow-up marker, and antibodies against it must also be checked because they interfere with measurement.
Key points
- Papillary cancer is the most common and spreads to nodes, and follicular spreads through the blood to bone and lung.
- Differentiated tumours are treated with surgery, radioactive iodine by risk and TSH suppression, and followed with thyroglobulin.
- Medullary cancer comes from C cells, does not take up iodine, and is followed with calcitonin and CEA; test RET and MEN2.
- Calcitonin that stays raised after surgery requires imaging, and the higher it is the more distant metastases are sought too.
- Anaplastic cancer is an emergency: airway, biopsy and BRAF testing for treatment with dabrafenib and trametinib.
Summary table
| Type | Features | Treatment |
|---|---|---|
| Papillary | The most common; psammoma bodies; BRAF V600E or RET changes; spread to neck nodes | Low-risk tumour 1 to 4 cm — lobectomy; above 4 cm, extrathyroidal extension or metastases — total thyroidectomy and iodine by risk |
| Follicular | Capsular and vascular invasion; blood-borne spread to bone and lung | Total thyroidectomy and radioactive iodine by risk |
| Follow-up in differentiated cancer | Thyroglobulin and its antibodies, and neck ultrasound | TSH suppression by risk level |
| Radioactive iodine refractory | Lenvatinib or sorafenib; targeted therapy by RET, NTRK or BRAF | When disease is progressive and symptomatic |
| Medullary | C cells; calcitonin and CEA; RET mutation; part of MEN2A and MEN2B | Total thyroidectomy with central node clearance; no role for iodine; selpercatinib for RET |
| Raised calcitonin after medullary surgery | Imaging for residual disease: neck ultrasound, and above 150 pg/mL also CT and liver and bone MRI | Calcitonin doubling time predicts prognosis |
| Anaplastic | Rapidly growing neck mass in an older patient, hoarseness, tracheal deviation | Urgent biopsy, secure the airway and test BRAF; BRAF V600E — dabrafenib with trametinib |
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Sources
- American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer, 2015 — Initial management and radioactive iodine
- American Thyroid Association Guidelines for the Management of Medullary Thyroid Carcinoma, 2015 — Postoperative management
- NCCN Clinical Practice Guidelines in Oncology: Thyroid Carcinoma, 2026 — Anaplastic carcinoma and systemic therapy
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.