Listing 13.09 Thyroid Gland Cancer in 2026
Thyroid cancer is one of the most common endocrine malignancies but has widely varying outcomes depending on histologic subtype. The American Cancer Society projects 44,020 new US thyroid cancer cases (12,150 men, 31,870 women) with 2,290 deaths in 2026. Most patients have differentiated thyroid cancer (DTC) with excellent survival (5-year overall over 98% for stage I papillary), but a small minority develop distant metastases, radioactive iodine (RAI) refractory disease, or the aggressive anaplastic variant with median survival of only 3-6 months.
SSA Listing 13.09 covers thyroid gland cancer with two paragraphs plus special rules for medullary and anaplastic variants. This walkthrough covers histologic subtypes, molecular testing (BRAF, RAS, RET, NTRK, TERT), RAI-refractory determination, modern TKI and targeted therapy, and the surgical and endocrine residuals after total thyroidectomy.
See If You Qualify
The listing text
Paragraph A: Anaplastic (undifferentiated) carcinoma of the thyroid gland
Anaplastic thyroid carcinoma automatically qualifies. It represents 1-2% of thyroid cancers but causes the majority of thyroid cancer deaths. Median OS is 3-6 months from diagnosis. Almost all patients present with rapidly growing neck mass, invasion of adjacent structures (trachea, esophagus, larynx, great vessels), and often distant metastases (lung, bone, brain).
Paragraph B: Carcinoma of the thyroid gland with metastases beyond regional nodes progressive despite radioactive iodine therapy
Differentiated thyroid cancer (papillary or follicular) that has metastasized beyond regional cervical lymph nodes AND is progressive despite radioactive iodine therapy meets Paragraph B. This targets RAI-refractory metastatic disease. Regional nodes include cervical (levels I-VII) and superior mediastinal nodes. Metastases beyond these to distant organs (lung, bone, brain, liver) plus RAI refractoriness qualifies.
Medullary thyroid cancer with metastases beyond regional nodes
MTC does not respond to radioactive iodine (arises from parafollicular C cells, not follicular cells). Metastases beyond regional cervical/upper mediastinal nodes meet the listing.
Thyroid cancer histologic subtypes
Papillary thyroid cancer (85% of thyroid cancer)
Well-differentiated, arises from follicular cells. Typically indolent with excellent prognosis. Multifocality common. Spreads primarily through lymphatics to cervical nodes. Molecular drivers: BRAF V600E (60% of PTC), RAS mutations, RET/PTC rearrangements, NTRK fusions, TERT promoter mutations (associated with aggressive behavior).
Follicular thyroid cancer (12%)
Well-differentiated, arises from follicular cells. Diagnosis requires demonstration of capsular or vascular invasion. Spreads hematogenously to lung and bone. Molecular drivers: RAS mutations, PAX8-PPARgamma fusions.
Hurthle cell (oncocytic) carcinoma (3%)
Follicular cell derivative with oxyphilic cytoplasm. More aggressive than typical follicular, less RAI-avid, higher recurrence risk.
Medullary thyroid cancer (3-4%)
Arises from parafollicular C cells (calcitonin-producing neural crest derived). Sporadic (75%) or hereditary as part of MEN2A, MEN2B, or familial MTC (25%). Germline RET mutations cause hereditary forms. Calcitonin is the tumor marker (very high in advanced disease). Somatic RET M918T mutation in sporadic MTC drives aggressive behavior.
Anaplastic (undifferentiated) thyroid cancer (1-2%)
Dedifferentiated aggressive variant. Often arises from pre-existing differentiated thyroid cancer through loss of differentiation. BRAF V600E present in 20-40%. TP53 mutations near universal. Median OS 3-6 months. Automatic qualification under 13.09A.
Molecular testing (2026 standard)
- BRAF V600E: 60% of PTC, drives dabrafenib + trametinib in anaplastic and RAI-refractory PTC
- RET fusions: papillary thyroid cancer, drives selpercatinib and pralsetinib
- RET mutations: medullary thyroid cancer (germline in MEN2 or somatic), drives selpercatinib
- NTRK fusions: rare in PTC, targets larotrectinib or entrectinib
- ALK fusions: rare, targets alectinib
- RAS mutations: no direct target but predicts follicular pattern
- TERT promoter mutations: aggressive behavior marker
- TP53: near universal in anaplastic
Radioactive iodine refractory (RAI-R) definition
Considered RAI-refractory when:
- Metastases do not concentrate iodine on post-therapy scan
- Loss of iodine avidity in previously RAI-avid lesions
- Progression despite RAI (usually within 6-12 months of last dose)
- Cumulative RAI activity greater than 600 mCi without response
RAI-refractory disease shifts management to TKI or targeted therapy.
Modern treatment
Total thyroidectomy + central neck dissection +/- lateral neck dissection
Standard for most thyroid cancers except very small T1a papillary microcarcinomas (which may be observed or receive lobectomy).
Radioactive iodine (I-131)
Adjuvant for intermediate/high-risk DTC. Doses vary: 30 mCi remnant ablation, 100-150 mCi for high-risk, up to 200+ mCi for known metastases. Requires thyroid hormone withdrawal or recombinant TSH stimulation.
TSH suppression with levothyroxine
Chronic suppressive dose of levothyroxine to keep TSH below 0.1 mIU/L in high-risk patients. Long-term risks: osteoporosis, atrial fibrillation, cardiac hypertrophy.
Lenvatinib (SELECT trial)
Multi-kinase TKI. First-line for RAI-refractory DTC. Progression-free survival about 18 months vs 4 months placebo. Toxicities: hypertension (universal, often severe), diarrhea, fatigue, proteinuria, hand-foot syndrome, weight loss, thromboembolism.
Sorafenib (DECISION trial)
Alternative TKI for RAI-refractory DTC. Toxicities similar to lenvatinib plus hand-foot skin reaction.
Selpercatinib and pralsetinib (RET inhibitors)
Highly effective for RET-altered thyroid cancer (RET fusions in PTC, RET mutations in MTC). Response rates 60-70% in MTC, 80%+ in RET-fusion PTC. Toxicities: hypertension, LFT abnormalities, edema, dry mouth.
Cabozantinib and vandetanib (MTC)
Multi-kinase TKIs approved for progressive MTC. Vandetanib carries QT prolongation black box warning.
Dabrafenib + trametinib (anaplastic + RAI-refractory PTC with BRAF V600E)
BRAF + MEK inhibitor combination. Response rates over 60% in BRAF-mutated anaplastic. Toxicities: pyrexia, rash, fatigue, ejection fraction decrease.
Larotrectinib and entrectinib (NTRK inhibitors)
For rare NTRK fusion-positive thyroid cancers.
Post-thyroidectomy residuals
Permanent hypoparathyroidism (5-10% after total thyroidectomy)
Damage to parathyroid glands during surgery. Requires lifelong calcium + calcitriol supplementation. Chronic hypocalcemia symptoms: tetany, paresthesias, muscle cramps, cognitive impairment, cataracts (long-term), basal ganglia calcification, dental abnormalities. Refractory cases may need PTH replacement therapy.
Recurrent laryngeal nerve injury (1-2% permanent unilateral, higher in reoperations)
Vocal cord paralysis causing hoarseness, aspiration, breathy voice. Bilateral injury can require tracheostomy.
Chronic voice changes
Even without frank RLN injury, voice quality can be affected by scar tissue and superior laryngeal nerve stretching.
Chronic post-neck dissection pain and stiffness
Cervical plexus nerve injury, spinal accessory nerve stretch, cosmetic scars, chronic lymphedema.
Long-term levothyroxine dependence
Universal after total thyroidectomy. Regular TSH monitoring, dose adjustments for pregnancy, weight change, aging, drug interactions.
RAI-related toxicities
Xerostomia and salivary gland dysfunction (chronic, up to 30%), altered taste, dental caries acceleration, increased risk of secondary malignancy (leukemia, salivary gland cancer, bladder cancer at high cumulative doses), male infertility, ovarian reserve reduction.
Worked case examples
Case 1: Maria, 61, Florida, anaplastic thyroid cancer with BRAF V600E
Maria presented with rapidly enlarging neck mass and dyspnea January 2026. CT neck showed 6 cm thyroid mass invading trachea. Emergency tracheostomy performed. Biopsy: anaplastic thyroid carcinoma, BRAF V600E positive. Staging: lung metastases. Started dabrafenib + trametinib per approved indication.
SSDI application filed February 2026. Anaplastic thyroid cancer auto-qualifies under Listing 13.09A. Approved 8 days at Florida DDS. Partial response at 3 months. Ongoing on targeted therapy. Chronic tracheostomy dependence.
Case 2: David, 54, Pennsylvania, RAI-refractory metastatic papillary thyroid cancer on lenvatinib
David diagnosed with PTC 2020, treated with total thyroidectomy + RAI 150 mCi. Recurrent disease 2023 with lung and bone metastases. Received additional RAI 200 mCi with no response. Determined RAI-refractory January 2026. Molecular testing: BRAF V600E positive. Started lenvatinib.
SSDI application filed February 2026. Listing 13.09B met (RAI-refractory metastatic disease). Approved 5 weeks at Pennsylvania DDS. Grade 3 hypertension requiring 4 antihypertensives, chronic diarrhea, 30 lb weight loss on lenvatinib.
Case 3: Angela, 45, New York, medullary thyroid cancer with RET M918T and liver metastases on selpercatinib
Angela presented with palpable thyroid mass, calcitonin 3,200 pg/mL (normal under 10) October 2025. FNA: medullary thyroid carcinoma. Genetic testing: no germline RET mutation. Underwent total thyroidectomy + bilateral neck dissection. Post-op calcitonin remained 800 pg/mL. Imaging showed liver metastases. Somatic RET M918T identified. Started selpercatinib.
SSDI application filed December 2025. Listing 13.09B met (MTC metastases beyond regional nodes). Approved 4 weeks at New York DDS. Partial response with calcitonin declining to 80 pg/mL. Chronic hypocalcemia from post-op hypoparathyroidism requiring calcium 2g QID + calcitriol.
What to file with your application
- Pathology report with histologic type and grade
- Molecular testing: BRAF, RAS, RET, NTRK, TERT for DTC; RET for MTC (germline + somatic)
- Serum thyroglobulin (DTC) or calcitonin (MTC) trend
- Post-thyroidectomy RAI whole body scan for DTC
- Cross-sectional imaging (CT chest, neck ultrasound, bone scan or FDG-PET for RAI-refractory disease)
- DOTA-PET for MTC if available
- Operative note + final surgical pathology
- Documentation of RAI doses received and response (post-therapy scans)
- Determination of RAI-refractory status
- Oncology + endocrinology consultation notes
- Documentation of post-surgical complications (hypocalcemia, hoarseness)
Related reading
Full section walkthrough: Section 13.00 cancer basics. Other cancer listings: 13.14 lung, 13.19 liver, 13.24 prostate.
Frequently asked questions
Does every thyroid cancer qualify for SSDI?
No. Most differentiated thyroid cancer (papillary or follicular) has excellent prognosis and does not meet 13.09 after successful thyroidectomy + RAI. Only cases meeting Paragraph A (anaplastic) or Paragraph B (metastases beyond regional nodes progressive despite RAI, or MTC with distant nodal or organ metastases) qualify.
What is anaplastic thyroid cancer?
Rare aggressive undifferentiated variant representing 1-2% of thyroid cancer but causing the majority of thyroid cancer deaths. Median OS 3-6 months. Automatically qualifies under Listing 13.09A.
What does RAI-refractory mean?
Radioactive iodine refractory. Metastases that do not concentrate iodine or continue growing despite RAI therapy. Shifts management to TKI (lenvatinib, sorafenib) or targeted therapy.
How does medullary thyroid cancer differ?
MTC arises from parafollicular C cells (not follicular cells). Does not concentrate iodine (RAI ineffective). Produces calcitonin as tumor marker. 25% hereditary via MEN2 or familial MTC with germline RET mutations.
What is the CAL trigger for thyroid cancer?
Anaplastic thyroid cancer is on the CAL list. Advanced thyroid cancer with distant metastases also generally qualifies for expedited processing.
Can post-thyroidectomy hypocalcemia support disability?
Chronic severe hypocalcemia from permanent hypoparathyroidism requiring high-dose calcium + calcitriol with recurrent symptomatic episodes can support RFC-based analysis and may meet Listing 9.00 (endocrine disorders) framework at CDR.
Do I need genetic testing for MTC?
Yes. Germline RET mutation testing is standard for all MTC because 25% is hereditary (MEN2A, MEN2B, or familial MTC). Positive result triggers screening of family members and evaluation for pheochromocytoma and hyperparathyroidism.
Next steps
If you were diagnosed with anaplastic thyroid cancer, file for SSDI immediately with automatic qualification under 13.09A. If you have differentiated thyroid cancer with distant metastases and RAI-refractory status, or MTC with metastases beyond regional nodes, file under Paragraph B.