Thyroid nodule medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
The goals of initial therapy of DTC are follows:
- To remove the primary tumor, disease that has extended beyond the thyroid capsule, and involved cervical lymph nodes. Completeness of surgical resection is an important determinant of outcome, while residual metastatic lymph nodes represent the most common site of disease persistence=recurrence
Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS 1993 Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989. Surgery 114:1050–1057; discussion 1057–1058. 117.
Shah MD, Hall FT, Eski SJ, Witterick IJ, Walfish PG, Freeman JL 2003 Clinical course of thyroid carcinoma after neck dissection. Laryngoscope 113:2102–2107. 118.
Wang TS, Dubner S, Sznyter LA, Heller KS 2004 Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes. Arch Otolaryngol Head Neck Surg 130:110– 113
- To minimize treatment-related morbidity. The extent of surgery and the experience of the surgeon both play important roles in determining the risk of surgical complications
Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R 1998 The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330. 120.
Friedman M, Pacella BL, Jr 1990 Total versus subtotal thyroidectomy. Arguments, approaches, and recommendations. Otolaryngol Clin North Am 23:413–427
- To permit accurate staging of the disease. Because disease staging can assist with initial prognostication, disease management, and follow-up strategies, accurate postoperative staging is a crucial element in the management of patients with DTC
Brierley JD, Panzarella T, Tsang RW, Gospodarowicz MK, O’Sullivan B 1997 A comparison of different staging systems predictability of patient outcome. Thyroid carcinoma as an example. Cancer 79:2414–2423. 122.
Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, Maurer MS, McIver B, Mullan BP, Oberg AL, Powell CC, van Heerden JA, Goellner JR 2002 Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940–1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients. World J Surg 26:879–885
- To facilitate postoperative treatment with radioactive iodine, where appropriate. For patients undergoing RAI remnant ablation, or RAI treatment of residual or metastatic disease, removal of all normal thyroid tissue is an important element of initial surgery . Near total or total thyroidectomy also may reduce the risk for recurrence within the contralateral lobe
Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY 1998 Use of radioactive iodine for thyroid remnant ablation in welldifferentiated thyroid carcinoma to replace thyroid reoperation. Am J Clin Oncol 21:77–81.
Esnaola NF, Cantor SB, Sherman SI, Lee JE, Evans DB 2001 Optimal treatment strategy in patients with papillary thyroid cancer: a decision analysis. Surgery 130:921–930
- To permit accurate long-term surveillance for disease recurrence. Both RAI whole-body scanning (WBS) and measurement of serum Tg are affected by residual normal thyroid tissue. Where these approaches are utilized for long-term monitoring, near-total or totalthyroidectomy is required
Mazzaferri EL 1999 An overview of the management of papillary and follicular thyroid carcinoma. Thyroid 9:421–427.
- To minimize the risk of disease recurrence and metastatic spread. Adequate surgery is the most important treatment variable influencing prognosis, while radioactive iodine treatment, TSH suppression, and external beam irradiation each play adjunctive roles in at least some patients
Kim TH, Yang DS, Jung KY, Kim CY, Choi MS 2003 Value of external irradiation for locally advanced papillary thyroid cancer. Int J Radiat Oncol Biol Phys 55:1006–1012
It is recommended to use thryoid hormone in iodine insufficient areas as a treatment for benign thyroid nodules. Thyroid hormone in doses that suppress the serum TSH to subnormal levels may result in a decrease in nodule size and may prevent the appearance of new nodules in regions of the world with borderline low iodine intake but in iodine sufficient areas, there are insufficient evidence of beneficial effect of thyroid hormone treatment for benign thyroid nodules
In pregnant women with FNA that is suspicious for or diagnostic of PTC, consideration could be given to administration of LT4 therapy to keep the TSH in the range of 0.1–1 mU=L
Kuy S, Roman SA, Desai R, Sosa JA 2009 Outcomes following thyroid and parathyroid surgery in pregnant women. Arch Surg 144:399–406. 109.
Rosen IB, Korman M, Walfish PG 1997 Thyroid nodular disease in pregnancy: current diagnosis and management. Clin Obstet Gynecol 40:81–89
postoperative RAI remnant ablation
Ablation of the remaining lobe with radioactive iodine has been used as an alternative to completion thyroidectomy
Randolph GW, Daniels GH 2002 Radioactive iodine lobe ablation as an alternative to completion thyroidectomy for follicular carcinoma of the thyroid. Thyroid 12:989–996.
Recombinant human TSH–mediated therapy
Recombinant human TSH–mediated therapy may be indicated in selected patients with underlying comorbidities making iatrogenic hypothyroidism potentially risky, in patients with pituitary disease who are unable to raise their serum TSH, or in patients in whom a delay in therapy might be deleterious. Such patients should be given the same or higher activity that would have been given had they been prepared with hypothyroidism or a dosimetrically determined activity
Vargas GE, Uy H, Bazan C, Guise TA, Bruder JM 1999 Hemiplegia after thyrotropin alfa in a hypothyroid patient with thyroid carcinoma metastatic to the brain. J Clin Endocrinol Metab 84:3867–3871. 355.
Robbins RJ, Voelker E, Wang W, Macapinlac HA, Larson SM 2000 Compassionate use of recombinant human thyrotropin to facilitate radioiodine therapy: case report and review of literature. Endocr Pract 6:460–464. 356.
Braga M, Ringel MD, Cooper DS 2001 Sudden enlargement of local recurrent thyroid tumor after recombinant human TSH administration. J Clin Endocrinol Metab 86:5148–5151
Metastases treatment:
Treatment of endocrine metastases should be based on:
- Size of metastatic lesions (macronodular typically detected by chest radiography; micronodular typically detected by CT; lesions beneath the resolution of CT)
- Avidity for RAI and, if applicable, response to prior RAI therapy
- Stability absence of metastatic lesions
| Metastases | Treatment | ||
|---|---|---|---|
| pulmonary metastases | Micrometastases | RAI therapy, and repeated every 6–12 months as long as disease continues to concentrate RAI and respond clinically, because the highest rates of complete remission are reported in these subgroups | |
| macronodular metastases | RAI and treatment should be repeated when objective benefit is demonstrated (decrease in the size of the lesions, decreasing Tg), but complete remission is not common and survival remains poor. The selection of RAI activity to administer can be made empirically (100–200 mCi) or estimated by lesional dosimetry or dosimetry to limit wholebody retention to 80 mCi at 48 hours and 200 cGy to the red bone marrow. | ||
| brain metastases | Complete surgical resection of CNS metastases should be considered regardless of RAI avidity
CNS lesions that are not amenable to surgery should be considered for external beam irradiation. Whole brain and spine irradiation could be considered if multiple metastases are present. |
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| bone metastases | Complete surgical resection of isolated symptomatic metastases
RAI therapy of iodine-avid bone metastases |
Pulmonary pneumonitis and fibrosis are rare complications of high-dose radioactive iodine treatment