What is true regarding Hurthle cell (HCC) thyroid carcinoma?

Hürthle Cell Thyroid Carcinoma: Key Clinical Features

The correct answer is C: Hürthle cell carcinoma often metastasizes to cervical lymph nodes, requiring total thyroidectomy with consideration for central neck dissection when lymph nodes are involved. 1, 2

Treatment Requirements (Addressing Option A)

Total thyroidectomy is the standard treatment for Hürthle cell carcinoma, but it is NOT adequate as monotherapy alone. 1 The complete treatment approach includes:

• Total thyroidectomy is mandatory as the initial surgical procedure, not lobectomy, due to HCC's more aggressive behavior compared to other differentiated thyroid cancers 1
• Central neck dissection (level VI) is recommended when lymph nodes are positive 1
• Lateral neck dissection (levels II-IV, consider level V) should be performed if lateral nodes are involved 1, 2, 3
• TSH suppression therapy with levothyroxine must be administered to all patients postoperatively 1
• Radioactive iodine ablation should be considered for residual thyroid tissue, though fewer than 10% of HCCs take up radioiodine 1, 3

The statement that total thyroidectomy alone is "adequate" is therefore false—it requires multimodal therapy including hormonal suppression and consideration of RAI ablation. 1, 3

Bilateral Disease Pattern (Addressing Option B)

Option B is FALSE: HCC is frequently bilateral or multifocal, not seldom bilateral. 2

• HCC commonly presents as bilateral or multifocal disease within the thyroid gland 2
• While it may present as a solitary nodule initially, the tendency toward multifocality is well-documented 1, 2
• This multifocal nature is one reason total thyroidectomy is preferred over lobectomy 2

Lymph Node Metastases (Addressing Option C)

Option C is TRUE: HCC often metastasizes to cervical lymph nodes. 2, 3

• Lymph node metastases are present at surgery in a significant proportion of patients 4, 2
• HCC is associated with a high rate of locoregional recurrence 2
• The disease frequently presents with local invasion 2
• When central or lateral nodes are positive, modified radical neck dissection is indicated 3

This represents a key distinguishing feature requiring aggressive surgical management with lymph node dissection when clinically apparent disease is present. 1, 2

Radiation Association (Addressing Option D)

Option D is FALSE: There is NO established association between HCC and previous neck radiation exposure. 1

• Unlike papillary thyroid carcinoma, HCC lacks a documented relationship with prior radiation exposure 1
• In one series, only 1 of 13 patients had a history of childhood head and neck radiation, suggesting no clear causal relationship 4
• The NCCN guidelines do not list prior radiation as a risk factor specific to HCC 5

Clinical Pearls

Common pitfall: Treating HCC with lobectomy alone leads to inadequate management of this potentially aggressive cancer with multifocal tendencies. 1, 2

Diagnostic limitation: Molecular diagnostics are specifically NOT recommended for Hürthle cell neoplasms due to high false-positive rates (86% unnecessary surgery rate historically). 1

Prognosis consideration: The 10-year relative survival for HCC is approximately 76%, which is lower than papillary (93%) and follicular (85%) carcinomas, reflecting its more aggressive nature. 1