R. Michael Tuttle

Follow up Approaches in Thyroid Cancer: A Risk Adapted Paradigm

The primary goal in the follow up of thyroid cancer patients is to identify and treat persistent and recurrent disease at a time that minimizes morbidity and disease specific mortality. This article presents a risk-adapted follow-up paradigm to guide both intensity and methodology of follow-up testing based on initial risk stratification, ongoing risk stratification, and secondary risk stratification that incorporates each of the well-known risk factors for recurrence and death from thyroid cancer, with a response to therapy variable as well as duration of disease-free survival. With a proper understanding of the biology of the disease and with accurate assessments of response to therapy, clinicians are better able to tailor a risk-appropriate follow-up approach to individual patients, minimizing excessive testing while still providing adequate testing to detect clinically significant disease recurrence in a timely fashion.

Medical management of thyroid cancer: a risk adapted approach

Risk adapted treatment recommendations are dependent on accurate predictions of the risk of recurrence, risk of death, and likely sites of recurrence. When combined with response to therapy assessments and secondary risk stratification during follow‐up, this risk adapted approach will allow the clinician to tailor the aggressiveness of therapy and follow up to the risk of recurrence and death in individual patients. J. Surg. Oncol. 2008;97:712–716.

Radioactive iodine therapy in poorly differentiated thyroid cancer

Background A 55-year-old male was diagnosed with poorly differentiated thyroid cancer after total thyroidectomy, which was performed because of progressive enlargement of a dominant thyroid nodule. He developed an early cervical recurrence that was treated with modified neck dissection. He subsequently developed biopsy-proven progressive pulmonary metastases.Investigations Neck and chest CT scans, laboratory tests, CT-guided fine-needle aspiration biopsy, [18F]-2-fluoro-2-deoxy-D-glucose-PET scan, lesional dosimetry using 124I PET scan, diagnostic radioactive iodine (RAI) scanning, whole-body and blood RAI dosimetry, and single-photon-emission CT.Diagnosis Stage IV poorly differentiated thyroid cancer.Management Surgical resection of cervical recurrence, RAI therapy.

Radioiodine Dosimetry with Recombinant Human Thyrotropin

Although radioactive iodine (RAI) has been an essential tool in the management of thyroid cancer for more than 60 years, there continues to be a lack of scientific rigor regarding the optimal choice of administered activity for individual patients. Often, activities of 30–75 mCi are administered for RAI remnant ablation, 100–150 mCi for adjuvant therapy in patients at significant risk of having microscopic residual disease, while activities ranging from 150 to 250 mCi are usually reserved for treatment of known metastatic disease. In most cases, the activity selected is based on an empiric regimen without knowledge of the rate of RAI clearance or specific lesional dosimetry for that individual patient.

Thyroid Remnant Radioiodine Ablation with Recombinant Human Thyrotropin

Initial treatment for most patients with differentiated thyroid cancer seeks to eliminate the entire primary tumor, to obtain sufficient material to properly stage the tumor, and to prepare the patient for a comprehensive surveillance program [1]. This often includes a total thyroidectomy and radioactive iodine (RAI) remnant ablation (RRA). The goal of RRA is to eliminate not only normal thyroid cells but also to destroy any residual microscopic thyroid carcinoma that may remain following total thyroidectomy and appropriate lymph node dissection. RAI uptake into thyroid cells is enhanced by a preparatory low-iodine diet and elevated levels of thyrotropin (TSH). For the past 40–50 years, endogenous TSH production was stimulated by several weeks of a hypothyroid state induced by thyroid hormone withdrawal (THW) prior to RAI. However, moderate to severe hypothyroid symptoms significantly reduce the quality of life for many patients and delay the clearance of radioiodine from the whole body.

131I Treatment of Metastatic Thyroid Carcinoma Following Preparation by Recombinant Human Thyrotropin

Eradication of metastatic thyroid carcinoma is a challenge. This challenge is attributed to the marked reduction in iodine uptake and organification in thyroid cancer cells, the relatively slow and unpredictable rate of progression, and the generally high quality of life (QOL), even in those patients with widely metastatic lesions. Furthermore, relatively few studies have identified reliable predictors of the progression rate, the pattern of metastatic spread, or the sensitivity to 131I therapy. Patients and their physicians often continue to administer large amounts of 131I to lesions that appear iodine-avid, even in the absence of previous tumor responses. A common rationalization for this approach is that the subsequent progression would have been worse if another dose of 131I had not been administered.