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Georgiou MF, Nielsen JA, Chiriboga R, Kuker RA. An Artificial Intelligence System for Optimizing Radioactive Iodine Therapy Dosimetry. J Clin Med 2023; 13:117. [PMID: 38202124 PMCID: PMC10780192 DOI: 10.3390/jcm13010117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Thyroid cancer, specifically differentiated thyroid carcinoma (DTC), is one of the most prevalent endocrine malignancies worldwide. Radioactive iodine therapy (RAIT) using I-131 has been a standard-of-care approach for DTC due to its ability to ablate remnant thyroid disease following surgery, thus reducing the risk of recurrence. It is also used for the treatment of iodine-avid metastases. RAIT dosimetry can be employed to determine the optimal treatment dose of I-131 to effectively treat cancer cells while safeguarding against undesirable radiation effects such as bone marrow toxicity or radiation pneumonitis. Conventional dosimetry protocols for RAIT, however, are complex and time-consuming, involving multiple days of imaging and blood sampling. This study explores the use of Artificial Intelligence (AI) in simplifying and optimizing RAIT. A retrospective analysis was conducted on 83 adult patients with DTC who underwent RAIT dosimetry at our institution between 1996 and 2023. The conventional MIRD-based dosimetry protocol involved imaging and blood sampling at 4, 24, 48, 72, and 96 h post-administration of a tracer activity of I-131. An AI system based on a deep-learning neural network was developed to predict the maximum permissible activity (MPA) for RAIT using only the data obtained from the initial 4, 24, and 48 h time points. The AI system predicted the MPA values with high accuracy, showing no significant difference compared to the results obtained from conventional MIRD-based analysis utilizing a paired t-test (p = 0.351, 95% CI). The developed AI system offers the potential to streamline the dosimetry process, reducing the number of imaging and blood sampling sessions while also optimizing resource allocation. Additionally, the AI approach can uncover underlying relationships in data that were previously unknown. Our findings suggest that AI-based dosimetry may be a promising method for patient-specific treatment planning in differentiated thyroid carcinoma, representing a step towards applying precision medicine for thyroid cancer. Further validation and implementation studies are warranted to assess the clinical applicability of the AI system.
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Affiliation(s)
- Michalis F. Georgiou
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Joshua A. Nielsen
- Department of Radiology, Jackson Memorial Hospital, Miami, FL 33136, USA; (J.A.N.)
- Nuclear Medicine, Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - Rommel Chiriboga
- Department of Radiology, Jackson Memorial Hospital, Miami, FL 33136, USA; (J.A.N.)
| | - Russ A. Kuker
- Department of Radiology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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Kim SB, Lee MS, Song IH, Park HS, Kim SE. Theranostic Surrogacy of [ 123I]NaI for Differentiated Thyroid Cancer Radionuclide Therapy. Mol Pharm 2023. [PMID: 37294909 DOI: 10.1021/acs.molpharmaceut.3c00073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Precise dosimetry has gained interest for interpreting the response assessments of novel therapeutic radiopharmaceuticals, as well as for improving conventional radiotherapies such as the "one dose fits all" approach. Although radioiodine as same-element isotope theranostic pairs has been used for differentiated thyroid cancer (DTC), there are insufficient studies on the determination of its dosing regimen for personalized medicine and on extrapolating strategies for companion diagnostic radiopharmaceuticals. In this study, DTC xenograft mouse models were generated after validating iodine uptakes via sodium iodine symporter proteins (NIS) through in vitro assays, and theranostic surrogacy of companion radiopharmaceuticals was investigated in terms of single photon emission computed tomography (SPECT) imaging and voxel-level dosimetry. Following a Monte Carlo simulation, the hypothetical energy deposition/dose distribution images were produced as [123I]NaI SPECT scans with the use of 131I ion source simulation, and dose rate curves were used to estimate absorbed dose. For the tumor, a peak concentration of 96.49 ± 11.66% ID/g occurred 2.91 ± 0.42 h after [123I]NaI injection, and absorbed dose for 131I therapy was estimated as 0.0344 ± 0.0088 Gy/MBq. The absorbed dose in target/off-target tissues was estimated by considering subject-specific heterogeneous tissue compositions and activity distributions. Furthermore, a novel approach was proposed for simplifying voxel-level dosimetry and suggested for determining the minimal/optimal scan time points of surrogates for pretherapeutic dosimetry. When two scan time points were set to Tmax and 26 h and the group mean half-lives were applied to the dose rate curves, the most accurate absorbed dose estimates were determined [-22.96, 2.21%]. This study provided an experimental basis to evaluate dose distribution and is expected hopefully to improve the challenging dosimetry process for clinical use.
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Affiliation(s)
- Su Bin Kim
- Department of Applied Bioengineering, Graduate School of Convergence Science and Technology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Korea
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea
| | - Min Seob Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea
| | - In Ho Song
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea
| | - Hyun Soo Park
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Korea
| | - Sang Eun Kim
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea
- Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul 08826, Korea
- Advanced Institutes of Convergence Technology, 145 Gwanggyo-ro, Yeongtong-gu, Suwon 16229, Korea
- BIK Therapeutics Inc., 172 Dolma-ro, Bundang-gu, Seongnam 13605, Korea
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Valerio L, Maino F, Castagna MG, Pacini F. Radioiodine therapy in the different stages of differentiated thyroid cancer. Best Pract Res Clin Endocrinol Metab 2023; 37:101703. [PMID: 36151009 DOI: 10.1016/j.beem.2022.101703] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Differentiated thyroid cancer is the most frequent type of thyroid cancer with an increasing incidence in the last decades. The initial management is represented by surgical treatment followed by radioactive iodine therapy that includes remnant ablation, adjuvant treatment or treatment of metastatic disease. Radioactive iodine treatment is performed only in selected cases based on the risk of recurrence and mortality during follow up, according to American Joint Committee on Cancer Union for international Cancer Control Tumor, Node, Metastasis (AJCC/TNM) staging system and the 2015 American Thyroid Association (ATA) risk stratification system. This article will review the key factors to consider when planning radioactive iodine therapy in differentiated thyroid cancer patients after surgery and during follow up.
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Affiliation(s)
- Laura Valerio
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy - Viale Bracci 16, 53100, Siena, Italy.
| | - Fabio Maino
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy - Viale Bracci 16, 53100, Siena, Italy.
| | - Maria Grazia Castagna
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy - Viale Bracci 16, 53100, Siena, Italy.
| | - Furio Pacini
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy - Viale Bracci 16, 53100, Siena, Italy.
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I-124 PET/CT image-based dosimetry in patients with differentiated thyroid cancer treated with I-131: correlation of patient-specific lesional dosimetry to treatment response. Ann Nucl Med 2022; 36:213-223. [PMID: 35119623 DOI: 10.1007/s12149-021-01655-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/12/2021] [Indexed: 11/01/2022]
Abstract
PURPOSE The objective of this study is to evaluate the lesion absorbed dose (AD), biological effective dose (BED), and equivalent uniform dose (EUD) to clinical-response relationship in lesional dosimetry for 131I therapy. METHODS Nineteen lesions in four patients with metastatic differentiated thyroid cancer (DTC) were evaluated. The patients underwent PET/CT imaging at 2 h, 24 h, 48 h, 72 h, and 96 h post administration of ~ 33-65 MBq (0.89-1.76 mCi) of 124I before undergoing 131I therapy. The 124I PET/CT images were used to perform dosimetry calculations for 131I therapy. Lesion dose-rate values were calculated using the time-activity data and integrated over the measured time points to obtain AD and BED. The Geant4 toolkit was used to run Monte Carlo on spheres the same size as the lesions to estimate EUD. The lesion AD, BED, and EUD values were correlated with response data (i.e. change in lesion size pre- and post-therapy): complete response (CR, i.e. disappearance of the lesion), partial response (PR, i.e. any decrease in lesion length), stable disease (SD, i.e., no change in length), and progressive disease (PD, i.e., any increase in length). RESULTS The lesion responses were CR and PR (58%, 11/19 lesions), SD (21%, 4/19), and PD (21%, 4/19). For CR and PR lesions, the ADs, BEDs and EUDs were > 75 Gy for 82% (9/11) and < 75 Gy for 18% (2/11). The ADs and BEDs were < 75 Gy for SD and PD lesions. CONCLUSION By performing retrospective dosimetry calculations for 131I therapy based on 124I PET/CT imaging, we evaluated the correlation of three dosimetric quantities to lesional response. When lesion AD, BED, and EUD values were > 75 Gy, 47% (9/19) of the lesions had a CR or PR. The AD, BED, and EUD values for SD and PD lesions were < 75 Gy. The data presented herein suggest that the greater the lesion AD, BED, and/or EUD, the higher the probability of a therapeutic response to 131I therapy.
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Pandit-Taskar N, Iravani A, Lee D, Jacene H, Pryma D, Hope T, Saboury B, Capala J, Wahl RL. Dosimetry in Clinical Radiopharmaceutical Therapy of Cancer: Practicality Versus Perfection in Current Practice. J Nucl Med 2021; 62:60S-72S. [PMID: 34857623 DOI: 10.2967/jnumed.121.262977] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/22/2021] [Indexed: 12/25/2022] Open
Abstract
The use of radiopharmaceutical therapies (RPTs) in the treatment of cancers is growing rapidly, with more agents becoming available for clinical use in last few years and many new RPTs being in development. Dosimetry assessment is critical for personalized RPT, insofar as administered activity should be assessed and optimized in order to maximize tumor-absorbed dose while keeping normal organs within defined safe dosages. However, many current clinical RPTs do not require patient-specific dosimetry based on current Food and Drug Administration-labeled approvals, and overall, dosimetry for RPT in clinical practice and trials is highly varied and underutilized. Several factors impede rigorous use of dosimetry, as compared with the more convenient and less resource-intensive practice of empiric dosing. We review various approaches to applying dosimetry for the assessment of activity in RPT and key clinical trials, the extent of dosimetry use, the relative pros and cons of dosimetry-based versus fixed activity, and practical limiting factors pertaining to current clinical practice.
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Affiliation(s)
| | - Amir Iravani
- Washington University School of Medicine, St. Louis, Missouri
| | - Dan Lee
- Ochsner Medical Center, New Orleans, Louisiana
| | | | - Dan Pryma
- Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas Hope
- University of San Francisco, San Francisco, California; and
| | | | - Jacek Capala
- National Institutes of Health, Bethesda, Maryland
| | - Richard L Wahl
- Washington University School of Medicine, St. Louis, Missouri
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Dotinga M, Vriens D, van Velden F, Heijmen L, Nagarajah J, Hicks R, Kapiteijn E, de Geus-Oei LF. Managing radioiodine refractory thyroid cancer: the role of dosimetry and redifferentiation on subsequent I-131 therapy. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 64:250-264. [PMID: 32744039 DOI: 10.23736/s1824-4785.20.03264-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Poor responses to iodine-131 (I-131) therapy can relate to either low iodine uptake and retention in thyroid cancer cells or to increased radioresistance. Both mechanisms are currently termed radioactive iodine (RAI)-refractory (RAI-R) thyroid cancer but the first reflects unsuitability for I-131 therapy that can be evaluated in advance of treatment, whereas the other can only be identified post hoc. Management of both represents a considerable challenge in clinical practice as failure of I-131 therapy, the most effective treatment of metastatic thyroid cancer, is associated with a poor overall prognosis. The development of targeted therapies has shown substantial promise in the treatment of RAI-R thyroid cancer in progressive patients. Recent studies show that selective tyrosine kinase inhibitors (TKIs) targeting B-type rapidly accelerated fibrosarcoma kinase (BRAF) and mitogen-activated protein kinase (MEK) can be used as redifferentiation agents to re-induce RAI uptake, thereby (re)enabling I-131 therapy. The use of dosimetry prior- and post-TKI treatment can assist in quantifying RAI uptake and improve identification of patients that will benefit from I-131 therapy. It also potentially offers the prospect of calculating individualized therapeutic administered activities to enhance efficacy and limit toxicity. In this review, we present an overview of the regulation of RAI uptake and clinically investigated redifferentiation agents, both reimbursed and in experimental setting, that induce renewed RAI uptake. We describe the role of dosimetry in redifferentiation and subsequent I-131 therapy in RAI-R thyroid cancer, explain different dosimetry approaches and discuss limitations and considerations in the field.
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Affiliation(s)
- Maaike Dotinga
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands -
| | - Dennis Vriens
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Floris van Velden
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Linda Heijmen
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Nuclear Medicine, Technical University Munich, Munich, Germany
| | - Rodney Hicks
- Department of Molecular Imaging, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Ellen Kapiteijn
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Biomedical Photonic Imaging Group, University of Twente, Enschede, the Netherlands
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7
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Weber M, Binse I, Nagarajah J, Bockisch A, Herrmann K, Jentzen W. The role of 124I PET/CT lesion dosimetry in differentiated thyroid cancer. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2019; 63:235-252. [DOI: 10.23736/s1824-4785.19.03201-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Dunn LA, Sherman EJ, Baxi SS, Tchekmedyian V, Grewal RK, Larson SM, Pentlow KS, Haque S, Tuttle RM, Sabra MM, Fish S, Boucai L, Walters J, Ghossein RA, Seshan VE, Ni A, Li D, Knauf JA, Pfister DG, Fagin JA, Ho AL. Vemurafenib Redifferentiation of BRAF Mutant, RAI-Refractory Thyroid Cancers. J Clin Endocrinol Metab 2019; 104:1417-1428. [PMID: 30256977 PMCID: PMC6435099 DOI: 10.1210/jc.2018-01478] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/20/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT BRAFV600E mutant thyroid cancers are often refractory to radioiodine (RAI). OBJECTIVES To investigate the utility and molecular underpinnings of enhancing lesional iodide uptake with the BRAF inhibitor vemurafenib in patients with RAI-refractory (RAIR). DESIGN This was a pilot trial that enrolled from June 2014 to January 2016. SETTING Academic cancer center. PATIENTS Patients with RAIR, BRAF mutant thyroid cancer. INTERVENTION Patients underwent thyrotropin-stimulated iodine-124 (124I) positron emission tomography scans before and after ~4 weeks of vemurafenib. Those with increased RAI concentration exceeding a predefined lesional dosimetry threshold (124I responders) were treated with iodine-131 (131I). Response was evaluated with imaging and serum thyroglobulin. Three patients underwent research biopsies to evaluate the impact of vemurafenib on mitogen-activated protein kinase (MAPK) signaling and thyroid differentiation. MAIN OUTCOME MEASURE The proportion of patients in whom vemurafenib increased RAI incorporation to warrant 131I. RESULTS Twelve BRAF mutant patients were enrolled; 10 were evaluable. Four patients were 124I responders on vemurafenib and treated with 131I, resulting in tumor regressions at 6 months. Analysis of research tumor biopsies demonstrated that vemurafenib inhibition of the MAPK pathway was associated with increased thyroid gene expression and RAI uptake. The mean pretreatment serum thyroglobulin value was higher among 124I responders than among nonresponders (30.6 vs 1.0 ng/mL; P = 0.0048). CONCLUSIONS Vemurafenib restores RAI uptake and efficacy in a subset of BRAF mutant RAIR patients, probably by upregulating thyroid-specific gene expression via MAPK pathway inhibition. Higher baseline thyroglobulin values among responders suggest that tumor differentiation status may be a predictor of vemurafenib benefit.
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Affiliation(s)
- Lara A Dunn
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Eric J Sherman
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Shrujal S Baxi
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Vatche Tchekmedyian
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ravinder K Grewal
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Steven M Larson
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Keith S Pentlow
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sofia Haque
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - R Michael Tuttle
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Mona M Sabra
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Stephanie Fish
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Laura Boucai
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jamie Walters
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ronald A Ghossein
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Venkatraman E Seshan
- Department of Epidemiology–Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ai Ni
- Department of Epidemiology–Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Duan Li
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jeffrey A Knauf
- Human Oncology and Pathogenesis, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - David G Pfister
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - James A Fagin
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
- Human Oncology and Pathogenesis, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Alan L Ho
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York
- Correspondence and Reprint Requests: Alan L. Ho, MD, PhD, Memorial Sloan-Kettering Cancer Center, 300 East 66th Street, New York, New York 10065. E-mail:
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Ylli D, Van Nostrand D, Wartofsky L. Conventional Radioiodine Therapy for Differentiated Thyroid Cancer. Endocrinol Metab Clin North Am 2019; 48:181-197. [PMID: 30717901 DOI: 10.1016/j.ecl.2018.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article presents an overview of the use of radioactive iodine (131-I) in the treatment of patients with differentiated thyroid cancer. Topics reviewed include definitions; staging; the 2 principal methods for selection of 131-I dosage; the indications for ablation, adjuvant treatment, and treatment; the recommendations for the use of 131-I contained in the guidelines of the American Thyroid Association and the Society of Nuclear Medicine and Molecular Imaging; the dosage recommendations and selection of dosage approach for 131-I by these organizations; the use of recombinant human thyrotropin for radioiodine ablation, adjuvant therapy, or treatment; and the MedStar Washington Hospital Center approach.
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Affiliation(s)
- Dorina Ylli
- Thyroid Cancer Research Center, MedStar Health Research Institute, 110 Irving Street, Washington, DC 20010, USA
| | - Douglas Van Nostrand
- Department of Nuclear Medicine, Nuclear Medicine Research, MedStar Health Research Institute and MedStar Washington Hospital Center, 110 Irving Street, Washington, DC 20010, USA
| | - Leonard Wartofsky
- Thyroid Cancer Research Center, MedStar Health Research Institute, 110 Irving Street, Washington, DC 20010, USA.
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Postoperative serum thyroglobulin and neck ultrasound to drive decisions about iodine-131 therapy in patients with differentiated thyroid carcinoma: an evidence-based strategy? Eur J Nucl Med Mol Imaging 2018; 45:2155-2158. [DOI: 10.1007/s00259-018-4110-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 07/25/2018] [Indexed: 01/13/2023]
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Howard BA, James OG, Perkins JM, Pagnanelli RA, Borges-Neto S, Reiman RE. A practical method of I-131 thyroid cancer therapy dose optimization using estimated effective renal clearance. SAGE Open Med Case Rep 2017; 5:2050313X17745203. [PMID: 29242746 PMCID: PMC5724631 DOI: 10.1177/2050313x17745203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/02/2017] [Indexed: 11/17/2022] Open
Abstract
In thyroid cancer patients with renal impairment or other complicating factors, it is important to maximize I-131 therapy efficacy while minimizing bone marrow and lung damage. We developed a web-based calculator based on a modified Benua and Leeper method to calculate the maximum I-131 dose to reduce the risk of these toxicities, based on the effective renal clearance of I-123 as measured from two whole-body I-123 scans, performed at 0 and 24 h post-administration.
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Affiliation(s)
- Brandon A Howard
- Division of Nuclear Medicine, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Olga G James
- Division of Nuclear Medicine, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Jennifer M Perkins
- Division of Endocrinology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert A Pagnanelli
- Division of Nuclear Medicine, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Salvador Borges-Neto
- Division of Nuclear Medicine, Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Robert E Reiman
- Division of Radiation Safety, Occupational and Environmental Safety Office, Duke University, Durham, NC, USA
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Van Nostrand D. Selected Controversies of Radioiodine Imaging and Therapy in Differentiated Thyroid Cancer. Endocrinol Metab Clin North Am 2017; 46:783-793. [PMID: 28760238 DOI: 10.1016/j.ecl.2017.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This article discusses the more controversial areas of the management of differentiated thyroid cancer, namely, the utility of pretherapy staging radioiodine scans; the prescribed activity for iodine-131 remnant ablation, adjuvant treatment, and distant metastases; preparation with thyroid hormone withdrawal versus recombinant human thyroid-stimulating hormone; and the classification of radioiodine refractory differentiated thyroid cancer. The author reviews various aspects of the controversies, such as the recommendations of the 2015 guidelines of the American Thyroid Association, arguments for and against the various controversies, and selected references.
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Affiliation(s)
- Douglas Van Nostrand
- Nuclear Medicine Research, Division of Nuclear Medicine, MedStar Health Research Institute, MedStar Washington Hospital Center, Georgetown University School of Medicine, Suite GA60F, 110 Irving Street, Northwest, Washington, DC 20010, USA.
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13
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Nichols KJ, Robeson W, Yoshida-Hay M, Zanzonico PB, Leveque F, Bhargava KK, Tronco GG, Palestro CJ. Alternative Means of Estimating 131I Maximum Permissible Activity to Treat Thyroid Cancer. J Nucl Med 2017; 58:1588-1595. [PMID: 28408530 DOI: 10.2967/jnumed.117.192278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/11/2017] [Indexed: 11/16/2022] Open
Abstract
To protect bone marrow from overirradiation, the maximum permissible activity (MPA) of 131I to treat thyroid cancer is that which limits the absorbed dose to blood (as a surrogate of marrow) to less than 200 cGy. The conventional approach (method 1) requires repeated γ-camera whole-body measurements along with blood samples. We sought to determine whether reliable MPA values can be obtained by simplified procedures. Methods: Data acquired over multiple time points were examined retrospectively for 65 thyroid cancer patients, referred to determine 131I uptake and MPA for initial treatment after thyroidectomy (n = 39), including 17 patients with compromised renal function and 22 patients with known (n = 16) or suspected (n = 6) metastases. The total absorbed dose to blood (DTotal) was the sum of mean whole-body γ-ray dose component (Dγ) from uncollimated γ-camera measurements and dose due to β emissions (Dβ) from blood samples. Method 2 estimated DTotal from Dβ alone, method 3 estimated DTotal from Dγ alone, and method 4 estimated DTotal from a single 48-h γ-camera measurement. MPA was computed as 200 cGy/DTotal for each DTotal estimate. Results: Method 2 had the strongest correlation with conventional method 1 (r = 0.98) and values similar to method 1 (21.0 ± 13.7 cGy/GBq vs. 21.0 ± 14.1 cGy/GBq, P = 0.11), whereas method 3 had a weaker (P = 0.001) correlation (r = 0.94) and method 4 had the weakest (P < 0.0001) correlation (r = 0.69) and lower dose (16.3 ± 14.8 cGy/GBq, P < 0.0001). Consequently, correlation with method 1 MPA was strongest for method 2 MPA (r = 0.99) and weakest for method 4 (r = 0. 75). Method 2 and method 1 values agreed equally well regardless of whether patients had been treated with 131I previously or had abnormal renal function. Conclusion: Because MPA based on blood measurements alone is comparable to MPA obtained with combined body counting and blood sampling, blood measurements alone are sufficient for determining MPA.
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Affiliation(s)
- Kenneth J Nichols
- Hofstra Northwell School of Medicine of Hofstra University, Manhasset and New Hyde Park, New York .,Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - William Robeson
- Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - Miyuki Yoshida-Hay
- Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - Pat B Zanzonico
- Memorial Hospital Research Laboratories, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fritzgerald Leveque
- Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - Kuldeep K Bhargava
- Hofstra Northwell School of Medicine of Hofstra University, Manhasset and New Hyde Park, New York.,Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - Gene G Tronco
- Hofstra Northwell School of Medicine of Hofstra University, Manhasset and New Hyde Park, New York.,Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
| | - Christopher J Palestro
- Hofstra Northwell School of Medicine of Hofstra University, Manhasset and New Hyde Park, New York.,Division of Nuclear Medicine and Molecular Imaging, Northwell Health, Manhasset and New Hyde Park, New York; and
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14
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Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26:1-133. [PMID: 26462967 PMCID: PMC4739132 DOI: 10.1089/thy.2015.0020] [Citation(s) in RCA: 8384] [Impact Index Per Article: 1048.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. METHODS The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members. RESULTS The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research. CONCLUSIONS We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.
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Affiliation(s)
| | - Erik K. Alexander
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Susan J. Mandel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Gregory W. Randolph
- Massachusetts Eye and Ear Infirmary, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna M. Sawka
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Julie Ann Sosa
- Duke University School of Medicine, Durham, North Carolina
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15
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Atkins F, Van Nostrand D, Moreau S, Burman K, Wartofsky L. Validation of a Simple Thyroid Cancer Dosimetry Model Based on the Fractional Whole-Body Retention at 48 Hours Post-Administration of (131)I. Thyroid 2015; 25:1347-50. [PMID: 26357962 DOI: 10.1089/thy.2014.0616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Standard dosimetric methods to determine the maximum tolerated activity (MTA) of (131)I for the treatment of metastatic, well-differentiated thyroid cancer (DTC) are time-consuming and require complex analysis. As a result, reliable, accurate, and simplified methods are desirable. The objective of this study was to evaluate the validity of a simple regression dosimetry model. METHOD Previously, the authors reported a bi-exponential model for estimating the MTA of (131)I for the treatment of metastatic DTC based on a limit of 2 Gy to the blood. This model uses the patient's body surface area (BSA) along with the fractional whole-body retention (WBR) at 48 hours following oral administration of a diagnostic dosage of (131)I. A bi-exponential regression model was developed between the MTA normalized to the patient's BSA and the percent retention value at the 48-hour time point (R): MTA (GBq)/BSA (m(2)) = (13.91 · e(-0.0387R) + 42.33 · e(-0.8522R)). In this study, the same model was applied to a different set of adult patients referred for dosimetry and possible (131)I treatment of DTC under conditions of thyroid hormone withdrawal or recombinant human thyrotropin (rhTSH) stimulation. All patients (n = 170; 96 female) referred to the authors' clinic for dosimetry and possible (131)I treatment for metastatic DTC during the collection period were included in this study, apart from those undergoing renal dialysis. The MTA predicted (MTAp) using the model described above was compared to the measured MTA (MTAm), with statistical analysis performed using ProStat v4.5. RESULTS In this group, the MTAm ranged from 2.3 to 41.1 GBq. The linear correlation between the MTAp and MTAm was excellent (r = 0.96), with an average deviation of only ± 1.2%. However, to avoid overdosing a patient on the basis of the MTAp, a weighting factor (<1.0) should be applied (e.g., using a value of 0.7 would result in only one patient receiving a prescribed activity of (131)I that exceeded the MTAm [<3%]). CONCLUSIONS The % 48-hour WBR as determined by the bi-exponential function noted herein with reasonable restrictions has been validated as a reliable simplified dosimetry model.
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Affiliation(s)
- Frank Atkins
- 1 Division of Nuclear Medicine, MedStar Washington Hospital Center , Washington, DC
| | - Douglas Van Nostrand
- 1 Division of Nuclear Medicine, MedStar Washington Hospital Center , Washington, DC
| | - Shari Moreau
- 1 Division of Nuclear Medicine, MedStar Washington Hospital Center , Washington, DC
| | - Kenneth Burman
- 2 Division of Endocrinology, MedStar Washington Hospital Center , Washington, DC
| | - Leonard Wartofsky
- 2 Division of Endocrinology, MedStar Washington Hospital Center , Washington, DC
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16
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Jentzen W, Bockisch A, Ruhlmann M. Assessment of Simplified Blood Dose Protocols for the Estimation of the Maximum Tolerable Activity in Thyroid Cancer Patients Undergoing Radioiodine Therapy Using 124I. J Nucl Med 2015; 56:832-8. [DOI: 10.2967/jnumed.114.153031] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/23/2015] [Indexed: 11/16/2022] Open
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17
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Pryma DA, Mandel SJ. Radioiodine therapy for thyroid cancer in the era of risk stratification and alternative targeted therapies. J Nucl Med 2014; 55:1485-91. [PMID: 25134528 DOI: 10.2967/jnumed.113.131508] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Differentiated thyroid cancers are typically iodine-avid and can be effectively treated with radioiodine. In most patients, radioiodine treatment is done for ablation of residual tissue, and in these cases the focus should be on using the minimum effective dose. Adjuvant therapy can be done to reduce the risk of recurrence, but optimal patient selection and dose are unclear. Patients with advanced disease benefit most from treatment with the maximum-tolerated dose. Recent research has focused on better patient selection and reduced radioiodine doses for remnant ablation. There are emerging targeted therapeutic approaches in patients who are appropriately shown to have iodine-refractory disease, with 1 drug approved by the Food and Drug Administration. Numerous trials are ongoing to assess targeted therapeutics alone or in combination with radioiodine.
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Affiliation(s)
- Daniel A Pryma
- Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Susan J Mandel
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Esposito G. Initial radioiodine administration: when to use it and how to select the dose. Endocrinol Metab Clin North Am 2014; 43:385-400. [PMID: 24891168 DOI: 10.1016/j.ecl.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
All published guidelines on the use of radioactive iodine for the treatment of well-differentiated thyroid cancer agree that an individualized assessment of the risk of cancer-related mortality and of disease recurrence should direct the decision of whether radioiodine treatment is needed and how much to administer. At the author's institution, they mostly follow the American Thyroid Association's risk stratification system, with the addition of a category of very-low-risk patients that do not receive radioactive iodine.
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Affiliation(s)
- Giuseppe Esposito
- Department of Radiology, Medstar Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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19
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Avram AM, Fig LM, Frey KA, Gross MD, Wong KK. Preablation 131-I scans with SPECT/CT in postoperative thyroid cancer patients: what is the impact on staging? J Clin Endocrinol Metab 2013; 98:1163-71. [PMID: 23430789 DOI: 10.1210/jc.2012-3630] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
CONTEXT The utility of preablation radioiodine scans for the management of differentiated thyroid cancer remains controversial. OBJECTIVE To determine the contribution of preablation Iodine 131 (131-I) planar with single-photon emission computed tomography/computed tomography (SPECT/CT; diagnostic [Dx] scans) to differentiated thyroid cancer staging. DESIGN Prospective sequential series at university clinic. METHODS Using American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging, seventh edition 320 patients post-total thyroidectomy were initially staged based on clinical and pathology data (pTN) and then restaged after imaging (TNM). The impact of Dx scans with SPECT/CT on N and M scores, and TNM stage, was assessed in younger, age <45 years, n = 138 (43%), and older, age ≥ 45 years, n = 182 (57%) patients, with subgroup analysis for T1a and T1b tumors. RESULTS In younger patients Dx scans detected distant metastases in 5 of 138 patients (4%), and nodal metastases in 61 of 138 patients (44%), including unsuspected nodal metastases in 24 of 63 (38%) patients initially assigned pathologic (p) N0 or pNx. In older patients distant metastases were detected in 18 of 182 patients (10%), and nodal metastases in 51 of 182 patients (28%), including unsuspected nodal metastases in 26 of 108 (24%) patients initially assigned pN0 or pNx. Dx scans detected distant metastases in 2 of 49 (4%) T1a, and 3 of 67 (4.5%) T1b patients. CONCLUSIONS Dx scans detected regional metastases in 35% of patients, and distant metastases in 8% of patients. Information acquired with Dx scans changed staging in 4% of younger, and 25% of older patients. Preablation scans with SPECT/CT contribute to staging of thyroid cancer. Identification of regional and distant metastases prior to radioiodine therapy has significant potential to alter patient management.
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MESH Headings
- Adenocarcinoma, Follicular/diagnosis
- Adenocarcinoma, Follicular/secondary
- Adenocarcinoma, Follicular/surgery
- Adenoma, Oxyphilic
- Adolescent
- Adult
- Age Factors
- Aged
- Aged, 80 and over
- Carcinoma/diagnosis
- Carcinoma/secondary
- Carcinoma/surgery
- Carcinoma, Papillary
- Child
- Female
- Humans
- Iodine Radioisotopes
- Lymphatic Metastasis/diagnostic imaging
- Male
- Middle Aged
- Neoplasm Staging
- Postoperative Complications/diagnostic imaging
- Postoperative Period
- Predictive Value of Tests
- Prospective Studies
- Thyroid Cancer, Papillary
- Thyroid Neoplasms/diagnosis
- Thyroid Neoplasms/secondary
- Thyroid Neoplasms/surgery
- Tomography, Emission-Computed, Single-Photon/methods
- Tomography, X-Ray Computed/methods
- Young Adult
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Affiliation(s)
- Anca M Avram
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109-5028, USA.
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20
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Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-80. [PMID: 22961916 DOI: 10.1210/er.2012-1030] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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21
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Van Nostrand D. Reply: Differentiated Thyroid Carcinoma: Is There Any Evidence for the Use of Recombinant Human TSH in Thyroid Hormone–Secreting Metastasis? J Nucl Med 2012. [DOI: 10.2967/jnumed.112.106617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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22
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Avram AM. Radioiodine scintigraphy with SPECT/CT: an important diagnostic tool for thyroid cancer staging and risk stratification. J Nucl Med 2012; 42:170-80. [PMID: 22550280 DOI: 10.2967/jnumed.111.104133] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Staging and risk stratification predicate the postoperative management of thyroid cancer patients, determining not only the need for (131)I therapy or alternative options (conservative management without ablation, surgical reintervention, or external-beam radiation therapy) but also the long-term follow-up strategy. This paper presents the progress made in the field of thyroid cancer imaging by application of SPECT/CT technology to radioiodine scintigraphy in both diagnostic and post-therapy settings and reviews the impact of fusion radioiodine imaging on staging, risk stratification, and clinical management of patients with thyroid cancer. In addition, this paper addresses the role of preablation radioiodine imaging and provides nuclear medicine physicians with the background knowledge required for integrating information from fusion imaging into the clinical and histopathologic risk stratification for developing an individualized treatment plan for patients with thyroid cancer.
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Affiliation(s)
- Anca M Avram
- Division of Nuclear Medicine/Radiology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-5028, USA.
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23
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Abstract
Targeted systemic radiotherapy constitutes the systemic administration of a radioactive agent that targets a molecule expressed preferentially on cancer cells. The archetypal such therapy is 131-iodine ((131)I) therapy for differentiated thyroid cancers. Radiotherapy typically delivers a calculated radiation-absorbed dose to tumor that takes into account (contiguous) normal tissue. Systemic radiotherapy development currently uses schema more analogous to chemotherapy--a radioactivity estimate that does not cause any irreversible toxicity. Historically, arbitrary amounts of radioactivity shown to be effective, on the basis of retrospective review, were used for thyroid cancer therapy with (131)I as well as for neuroendocrine tumor therapy with (131)I-labeled meta-iodo-benzylguanidine (MIBG). Their established safety record has led to adaptations that include repeat therapies with nontoxic amounts of radioactivity. There remains, however, a lack of clear understanding of the safety limits of systemic targeted radiotherapy. This is probably most true in systemic therapy with MIBG in adult neuroendocrine tumors. Bone marrow is the primary critical organ for most targeted systemic radiotherapy; second organ involvement may be renal, as with MIBG and targeted radiopeptide therapy, or pulmonary, as with radioimmunotherapy. Most therapies have tended toward multiple administrations of subtoxic amounts of radioactivity. Therapy with MIBG in pheochromococytoma as well as targeted radiopeptide therapy in medullary thyroid cancer has followed this model. Radioimmunotherapy appears very promising; a definitive Phase 2 study needs completion. All therapy has shown promise in extending disease survival (as compared with historical controls), with few major structural (or biochemical) responses. This review will attempt to compliment the excellent existing literature by providing an overall systemic therapeutic approach to this promising endeavor.
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24
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Rivkees SA, Mazzaferri EL, Verburg FA, Reiners C, Luster M, Breuer CK, Dinauer CA, Udelsman R. The treatment of differentiated thyroid cancer in children: emphasis on surgical approach and radioactive iodine therapy. Endocr Rev 2011; 32:798-826. [PMID: 21880704 PMCID: PMC3591676 DOI: 10.1210/er.2011-0011] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pediatric thyroid cancer is a rare disease with an excellent prognosis. Compared with adults, epithelial-derived differentiated thyroid cancer (DTC), which includes papillary and follicular thyroid cancer, presents at more advanced stages in children and is associated with higher rates of recurrence. Because of its uncommon occurrence, randomized trials have not been applied to test best-care options in children. Even in adults that have a 10-fold or higher incidence of thyroid cancer than children, few prospective trials have been executed to compare treatment approaches. We recognize that treatment recommendations have changed over the past few decades and will continue to do so. Respecting the aggressiveness of pediatric thyroid cancer, high recurrence rates, and the problems associated with decades of long-term follow-up, a premium should be placed on treatments that minimize risk of recurrence and the adverse effects of treatments and facilitate follow-up. We recommend that total thyroidectomy and central compartment lymph node dissection is the surgical procedure of choice for children with DTC if it can be performed by a high-volume thyroid surgeon. We recommend radioactive iodine therapy for remnant ablation or residual disease for most children with DTC. We recommend long-term follow-up because disease can recur decades after initial diagnosis and therapy. Considering the complexity of DTC management and the potential complications associated with therapy, it is essential that pediatric DTC be managed by physicians with expertise in this area.
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Affiliation(s)
- Scott A Rivkees
- Department of Pediatrics, Yale Child Health Research Center, Yale University School of Medicine, 464 Congress Avenue, Room 237, New Haven, Connecticut 06520, USA.
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25
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Wolff EF, Hughes M, Merino MJ, Reynolds JC, Davis JL, Cochran CS, Celi FS. Expression of benign and malignant thyroid tissue in ovarian teratomas and the importance of multimodal management as illustrated by a BRAF-positive follicular variant of papillary thyroid cancer. Thyroid 2010; 20:981-7. [PMID: 20718682 PMCID: PMC2964358 DOI: 10.1089/thy.2009.0458] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The most common type of ovarian germ cell tumor is the teratoma. Thyroid tissue, both benign and malignant, may be a component of an ovarian teratoma. Here we review this topic and illustrate major features by presenting multimodal management of a patient with BRAF-positive disseminated follicular thyroid cancer arising in an ovarian teratoma. SUMMARY Malignant thyroid tissue is often difficult to distinguish from benign thyroid tissue arising in ovarian teratomas. Preoperatively, an elevated thyroglobulin (Tg) level, laboratory or clinical evidence of hyperthyroidism, or ultrasonography appearance of "struma pearl" should prompt referral to oncologist for surgical management of a possibly malignant ovarian teratoma. Postoperatively, tumor tissue should be referred to pathologists experienced with differentiating benign from malignant struma ovarii. Once diagnosed, treatment of this rare condition should be handled by a team of specialists with combined treatment modalities. We cared for woman with disseminated thyroid cancer arising in an ovarian teratoma whose history illustrates the complexity of managing ovarian teratomas with malignant thyroid tissue. At age 33 she had an intraoperative rupture of an ovarian cyst, thought to be struma ovarii. During her next pregnancy, pelvic masses were noted; biopsies revealed well-differentiated papillary thyroid carcinoma, follicular variant. She was euthyroid, but had elevated serum Tg levels. Surgical staging demonstrated widely metastatic intraabdominal dissemination. A thyroidectomy revealed no malignancy. A post-(131)I treatment scan revealed diffuse uptake throughout the abdomen. She then developed abdominal pain and, on computed tomography, was found to have multiple intraabdominal foci of disease. Serum Tg was 264 ng/mL while on L-thyroxine for hypothyroidism and to obtain thyrotropin suppression. A 18 fluorodeoxyglucose positron emission tomography scan showed no pathological uptake. The tumor was found to be BRAF mutation positive (K601E). She underwent extensive secondary debulking and a second course of (131)I with lithium pretreatment. Posttreatment scan revealed diffuse abdominal uptake. Six months posttherapy, the patient is asymptomatic with a serum Tg of 18.1 ng/mL. CONCLUSIONS Aggressive multimodal management appears to be the most promising approach for malignant thyroid tissue arising in ovarian teratomas.
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Affiliation(s)
- Erin F. Wolff
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Marybeth Hughes
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Maria J. Merino
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Jeremy L. Davis
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Craig S. Cochran
- Clinical Endocrinology Branch, National Institute of Diabetes, Digestive, and Kidney Diseases; National Institutes of Health, Bethesda, Maryland
| | - Francesco S. Celi
- Clinical Endocrinology Branch, National Institute of Diabetes, Digestive, and Kidney Diseases; National Institutes of Health, Bethesda, Maryland
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26
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Abstract
BACKGROUND I-131 has been used in the therapy of well-differentiated thyroid cancer for over 50 years. Although the benefits and risks of I-131 remain issues of controversy and research, our understanding of them continues to improve. This review presents an overview of the benefits of I-131 therapy for ablation, adjuvant treatment, and treatment of locoregional and/or metastasis of well-differentiated thyroid cancer and considers the risks of complications of I-131 therapy. SUMMARY The benefits of I-131 remnant ablation include: [1] facilitating the interpretation of subsequent serum thyroglobulin levels, [2] increasing the sensitivity of detection of locoregional and/or metastatic disease on subsequent follow-up radioactive iodine whole-body scans, [3] maximizing the therapeutic effect of subsequent treatments, and [4] allowing a postablation scan to help identify additional sites of disease that were not identified on the preablation scan or when a preablation scan was not performed. The potential benefits of I-131 adjuvant treatment include decreasing recurrence and disease-specific mortality for unknown microscopic, locoregional, and/or distant metastatic disease. The potential benefits of I-131 treatment of known locoregional and/or distant metastases are [1] decreasing recurrence, and [2] decreasing disease-specific mortality and/or palliation. The more significant risks and side effects involve organ systems including eye/nasolacrimal, salivary, pulmonary, gastrointestinal, hematopoietic, and gonads as well as secondary primary malignancies. CONCLUSIONS Although there are never-ending controversies regarding I-131 therapy in well-differentiated thyroid cancer, the benefits and risks are becoming better understood. This in turn helps the treating physician and patient in making decisions regarding therapy.
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Affiliation(s)
- Douglas Van Nostrand
- Division of Nuclear Medicine, and Nuclear Medicine Residency Program, Washington Hospital Center , Washington, District of Columbia, USA.
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