Post-surgical follow-up of differentiated thyroid cancer

Revista Espanola De Medicina Nuclear, 2011

The Journal of Clinical Endocrinology and Metabolism, 2002

Measuring serum Tg and performing a diagnostic whole body scan (DxWBS) has become the standard for follow-up of patients with differentiated thyroid carcinoma. The primary aim of this study was to determine whether recombinant human TSH (rhTSH)-stimulated Tg alone is sufficiently sensitive to identify residual cancer in patients with no clinical evidence of disease and undetectable or very low serum Tg levels during thyroid hormone (TH) therapy. A secondary aim was to investigate the frequency of tumor in such patients. One hundred and seven consecutive patients, aged 10.9-85.3 yr (median, 36.3), at the time of initial surgery who had Tg levels on TH therapy that were undetectable (95% <0.5 ng/ml) or low (4% 0.6 ng/ml, 1% 1.0 ng/ml) and who underwent rhTSHstimulated testing 10 months to 35 yr (median, 3.5 yr) after initial thyroidectomy and 131 I ablation were retrospectively studied. Many (50%) were at high risk of tumor recurrence, and 5 had distant metastases during the course of their disease. In response to rhTSH, Tg ranged from 0.5 or less to 17.9 ng/ml, remaining at 0.5 ng/ml or less in 68 (64%) patients and increasing to levels between 0.6 and 2 ng/ml in 19 (18%) others and to levels higher than 2 ng/ml in 20 (19%) patients. Eleven patients (10%), all of whom had rhTSH-stimulated serum Tg levels above 2 ng/ml, were found to have persistent tumor in lung (4 patients), lymph nodes (5 patients, 3 with cervical central compartment, 1 bilateral cervical, and 1 with mediastinal nodes) identified by fine needle cytology, surgical pathology, posttherapy whole body scans, or computed tomography and, in two patients, with high serum Tg values alone (4.6 and 7.0 ng/ml after rhTSH and, respectively, 28.5 and 70.6 ng/ml after TH withdrawal), although in neither could the tumor site be identified. Thirteen patients (12%) were treated with surgery or 131 I, and in some cases both, as a result of the rhTSH studies; 10 had tumor, 1 had residual uptake in the thyroid bed visible on rhTSH-stimulated diagnostic whole body scan (DxWBS), and 2 had high serum Tg levels, presumably originating from a tumor site that could not be identified. A patient's tumor status, even in retrospect, usually was not predictable on the basis of Tg during TH therapy or tumor node metastasis status: among patients found to have tumor after rhTSH, serum Tg during TH therapy was 0.5 ng/ml or less in 55% and 0.6 ng/ml in 36%, and tumor node metastasis status was T2N1 or less in 82%. In no case did the rhTSH-stimulated DxWBS show the site of persistent tumor. There were correlations between visible thyroid bed uptake on DxWBS and quantitated 131 I uptake (r 2 ‫؍‬ 0.11; P ‫؍‬ 0.001), between DxWBS and rhTSH-stimulated Tg (r 2 ‫؍‬ 0.54; P ‫؍‬ 0.001), and between rhTSH-stimulated Tg and 131 I uptake (r 2 ‫؍‬ 0.66; P ‫؍‬ 0.0001). There was no statistically significant difference (P ‫؍‬ 0.4) in bed 131 I uptake in patients with rhTSH-stimulated serum Tg levels of 0.5 ng/ml or less compared with that in subjects with higher rhTSH-Tg levels. An rhTSH-stimulated Tg level greater than 2 ng/ml had a sensitivity of 100%, a negative predictive value of 100%, and a false positive rate of 9%. The rhTSH Tg had a substantially better performance than the other studies; the false negative rates were 64% for Tg higher than 0.5 ng/ml on TH therapy, 73% for rhTSH-stimulated DxWBS showing uptake, and zero for an rhTSH-stimulated Tg more than 2 ng/ml. In conclusion, of 107 patients who were clinically free of disease, 10% had persistent tumor (4 with pulmonary metastases and 5 with regional disease) that was only identified with an rhTSH-stimulated serum Tg level greater than 2 ng/ ml. This study shows that tumor amenable to early therapy may be found when rhTSH-stimulated serum Tg rises above 2 ng/ml without performing a DxWBS, which merely provides data concerning the completeness of thyroid ablation, but not persistent tumor. An elevated rhTSH-stimulated Tg greater than 2 ng/ml warrants further study.

Frontiers in Endocrinology

Background: In patients with differentiated thyroid cancer (DTC) and raising serum thyroglobulin (Tg) after total or near-total thyroidectomy and 131 I remnant ablation an empiric 131 I therapy may be considered. However, outcome data after empiric therapy in did not show a clear evidence of improved survival. We assessed the efficacy of such empiric 131 I therapy in patients with DTC and evaluated the long-term outcome. Methods: A total of 100 patients with DTC showing raised Tg level during follow-up after thyroidectomy and 131 I ablation were treated with a further 131 I therapy (6.1 ± 1.7 GBq). Whole-body scan (WBS) was performed 5-7 days after therapy. Tg value at 12 months after 131 I therapy was considered as an indicator of treatment response: ≤1.5 ng/ml complete remission (CR), >50% decrease partial remission (PR), higher than pre-therapy progression disease (PD), all other cases stable disease (SD). Patients were followed-up for 96 ± 75 months. Results: After 12 months, 62% of patients were in CR, 16% in PR, 8% in SD, and 14% in PD. WBS was positive in 41% of patients and negative in 59% (P = NS). Among patients with local recurrences at WBS 89% showed either CR or PR, while 71% of patients with distant metastases were in SD or PD (P < 0.001). Distant metastases at WBS (P < 0.05), CR (P < 0.0001), and CR + PR (P < 0.0001) were predictors of both progression free survival and overall survival. Conclusion: There is a beneficial effect of 131 I therapy on outcome of patients with DTC treated on the basis of elevated Tg value. In these patients, survival is affected by achievement of CR or PR at 12 months evaluation after 131 I therapy and by the presence of distant metastases at WBS.

European Journal of Nuclear Medicine and Molecular Imaging, 2010

Purpose In patients with advanced differentiated thyroid carcinoma (DTC), therapy with the highest safe 131 I activity is desirable to maximize the tumour radiation dose yet avoid severe myelotoxicity. Recently, the European Association of Nuclear Medicine (EANM) published a standard operational procedure (SOP) for pre-therapeutic dosimetry in DTC patients incorporating a safety threshold of a 2 Gy absorbed dose to the blood as a surrogate for the red marrow. We sought to evaluate the safety and effectiveness in everyday tertiary referral centre practice of treating advanced DTC with high 131 I activities chosen primarily based on the results of dosimetry following this SOP. Methods We retrospectively assessed toxicity as well as biochemical and scintigraphic response in our first ten patients receiving such therapy for advanced DTC. Results The 10 patients received a total of 13 dosimetrically guided treatments with a median administered activity of 14.0 GBq (range: 7.0-21.4 GBq) 131 I. After 6 of 13 treatments in 6 of 10 patients, short-term side effects of 131 I therapy, namely nausea, vomiting or sialadenitis, were observed. Leukocyte and platelet counts dropped significantly in the weeks after 131 I treatment, but returned to pre-treatment levels by 3 months post-therapy. Serum thyroglobulin levels decreased after 12 of 13 treatments (median reduction: 58%) in 9 of 10 patients. Conclusion In our initial patient cohort, high-activity 131 I therapy for advanced DTC based on pre-therapeutic blood dosimetry following the EANM SOP was safe and well tolerated. Such treatment almost always produced a partial biochemical tumour response.

Journal of Solid Tumors, 2013

Background: Thyroid stunning was defined as transient reduction of thyroid tissue uptake 131I (RAI-131) ablative dose after a diagnostic 131I dose that decreases the final absorbed dose in ablative therapy. Aim of the study: after following the proper precautions compare the response to the ablative dose given to patients with differentiated thyroid cancer with or without diagnostic radioactive iodine 131(RAI-131). Patients and methods: One hundred patients with differentiated thyroid cancer were included and divided into two groups: Group I, ablative dose of RAI-131according to their risk stratification without diagnostic dose and Group II, patients performing diagnostic whole body scan [5mCi] followed by ablative dose. Results: The current study have showed no significant associations between overall response in both groups and the different studied parameters except for the mean ablative dose of RAI-131 [r=0.9; P<0.001 and r=0.7, P<0.001 in group I and group II respectively]. Correlation matrix was used in all patients revealed that overall response was highly correlated with risk stratification; cervical nodal status and RAI-131 ablative dose [P values <0.01; <0.01 and <0.01 respectively], while regression proved that the only predictor for response is the mean RAI-131 ablative dose. Conclusion: Following the proper precautions prevent stunning appearance after the diagnostic dose success rate to ablation will not be affected.

The Journal of Clinical Endocrinology & Metabolism, 2001

Detectable serum Tg levels associated with negative diagnostic 131 I whole body scan are not infrequently found in patients with differentiated thyroid cancer. Several researchers have shown that in these patients the administration of high 131 I activity (100 mCi or more) increases the sensitivity of a posttherapy diagnostic 131 I whole body scan performed a few days later and allows the detection of neoplastic foci not seen with diagnostic doses of 131 I. Empirical radioiodine treatment has also been advocated by some researchers, but its therapeutic effect is controversial.

European Journal of Nuclear Medicine and Molecular Imaging, 2007

Purpose Using 123 I for diagnostic purposes avoids the risk of stunning for subsequent radioiodine treatment and affords an excellent image quality. In this study we assessed the role of 123 I in comparison with 131 I post-treatment imaging in patients with thyroid cancer. Methods We compared a total of 292 123 I scans with their corresponding post-treatment 131 I images. Patients received a therapeutic dose of 131 I following diagnostic scanning with 50-111 MBq of 123 I. All patients were in a hypothyroid state (>30 μIU/l) before radioiodine administration for either diagnostic or therapeutic purposes. Results In 228 out of 263 patients with a positive diagnostic scan, 123 I whole-body scan findings were concordant with those of corresponding post-treatment 131 I images (concordance rate 87%). However, there were 44 additional foci of abnormal uptake on post-treatment 131 I scans in 22 discordant cases with no impact on therapeutic management of the patients. In 13 patients, there was at least one new site on post-treatment images that had been missed on pretreatment 123 I images. Twenty-nine patients with a negative diagnostic scan were treated with 131 I owing to a high serum thyroglobulin level (range 11.3-480 ng/ml). Radioiodine uptake sites were seen in eight post-treatment scans. In 21 pairs of whole-body scans, both the pre-and the post-treatment scan were negative (concordance rate 72.4%). Conclusion 123 I scanning is comparable to high-dose 131 I post-treatment imaging in thyroid carcinoma patients, and 123 I offers excellent image quality as a diagnostic agent. It avoids disadvantages such as stunning before treatment and delivery of a high radiation dose to patients.

Journal of patient safety and quality improvement, 2019

Introduction: Finding optimum time of post ablation whole body iodine scan in patients with differentiated thyroid cancer(DTC) treated with I-131.Material and Methods: 20 patients with DTC, who were treated with I131 underwent post ablation whole body iodine scan (WBIS) in days 4, 7 and 9 after treatment. A dual head gamma camera (e-cam, Siemens) equipped with high energy parallel hole collimator was used for imaging. The images were acquired with 7cm/min and stored in a 1024 ×256 matrix. Results: 3 Patients had negative WBIS in all three sets of imaging and 17 patients had postsurgical thyroid remnants on all 3 scans. On days 4 and 7 we detected 11 patients with cervical lymph node metastases while on day 9 only 9 patients showed cervical lymph node metastases.(P=0.135)On all 3 sets of images, we encountered 4 patients with mediastinal lymph node metastases and 1 patient with bone metastasis. In addition, all 3 sets of images detected lung metastases in three patients. The total nu...

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