1
|
Wadsley J. Redifferentiation Therapy for Iodine Refractory Differentiated Thyroid Cancers: Current Status. Thyroid 2023; 33:662-663. [PMID: 36746919 DOI: 10.1089/thy.2023.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
2
|
Genco MT, Yaqub A, Jana S. Challenges in the evaluation and management of radioactive iodine-refractory differentiated thyroid cancer. Nucl Med Commun 2022; 43:743-745. [PMID: 35438680 DOI: 10.1097/mnm.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew T Genco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | | |
Collapse
|
3
|
Abstract
Trace elements, such as iodine and selenium (Se), are vital to human health and play an essential role in metabolism. They are also important to thyroid metabolism and function, and correlate with thyroid autoimmunity and tumors. Other minerals such as iron (Ir), lithium (Li), copper (Co), zinc (Zn), manganese (Mn), magnesium (Mg), cadmium (Cd), and molybdenum (Mo), may related to thyroid function and disease. Normal thyroid function depends on a variety of trace elements for thyroid hormone synthesis and metabolism. These trace elements interact with each other and are in a dynamic balance. However, this balance may be disturbed by the excess or deficiency of one or more elements, leading to abnormal thyroid function and the promotion of autoimmune thyroid diseases and thyroid tumors.The relationship between trace elements and thyroid disorders is still unclear, and further research is needed to clarify this issue and improve our understanding of how trace elements mediate thyroid function and metabolism. This paper systematically reviewed recently published literature on the relationship between various trace elements and thyroid function to provide a preliminary theoretical basis for future research.
Collapse
Affiliation(s)
- Qing Zhou
- Department of Thyroid Surgery, General Surgery Center, The Hospital of Jilin University, Changchun, China
| | - Shuai Xue
- Department of Thyroid Surgery, General Surgery Center, The Hospital of Jilin University, Changchun, China
- *Correspondence: Shuai Xue, ; Guang Chen,
| | - Li Zhang
- Department of Nephrology, The Hospital of Jilin University, Changchun, China
| | - Guang Chen
- Department of Thyroid Surgery, General Surgery Center, The Hospital of Jilin University, Changchun, China
- *Correspondence: Shuai Xue, ; Guang Chen,
| |
Collapse
|
4
|
Oh JM, Ahn BC. Molecular mechanisms of radioactive iodine refractoriness in differentiated thyroid cancer: Impaired sodium iodide symporter (NIS) expression owing to altered signaling pathway activity and intracellular localization of NIS. Theranostics 2021; 11:6251-6277. [PMID: 33995657 PMCID: PMC8120202 DOI: 10.7150/thno.57689] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/22/2021] [Indexed: 12/16/2022] Open
Abstract
The advanced, metastatic differentiated thyroid cancers (DTCs) have a poor prognosis mainly owing to radioactive iodine (RAI) refractoriness caused by decreased expression of sodium iodide symporter (NIS), diminished targeting of NIS to the cell membrane, or both, thereby decreasing the efficacy of RAI therapy. Genetic aberrations (such as BRAF, RAS, and RET/PTC rearrangements) have been reported to be prominently responsible for the onset, progression, and dedifferentiation of DTCs, mainly through the activation of mitogen-activated protein kinase (MAPK) and phosphoinositide 3-kinase (PI3K)/AKT signaling pathways. Eventually, these alterations result in a lack of NIS and disabling of RAI uptake, leading to the development of resistance to RAI therapy. Over the past decade, promising approaches with various targets have been reported to restore NIS expression and RAI uptake in preclinical studies. In this review, we summarized comprehensive molecular mechanisms underlying the dedifferentiation in RAI-refractory DTCs and reviews strategies for restoring RAI avidity by tackling the mechanisms.
Collapse
|
5
|
Lorusso L, Cappagli V, Valerio L, Giani C, Viola D, Puleo L, Gambale C, Minaldi E, Campopiano MC, Matrone A, Bottici V, Agate L, Molinaro E, Elisei R. Thyroid Cancers: From Surgery to Current and Future Systemic Therapies through Their Molecular Identities. Int J Mol Sci 2021; 22:3117. [PMID: 33803747 PMCID: PMC8003273 DOI: 10.3390/ijms22063117] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 12/16/2022] Open
Abstract
Differentiated thyroid cancers (DTC) are commonly and successfully treated with total thyroidectomy plus/minus radioiodine therapy (RAI). Medullary thyroid cancer (MTC) is only treated with surgery but only intrathyroidal tumors are cured. The worst prognosis is for anaplastic (ATC) and poorly differentiated thyroid cancer (PDTC). Whenever a local or metastatic advanced disease is present, other treatments are required, varying from local to systemic therapies. In the last decade, the efficacy of the targeted therapies and, in particular, tyrosine kinase inhibitors (TKIs) has been demonstrated. They can prolong the disease progression-free survival and represent the most important therapeutic option for the treatment of advanced and progressive thyroid cancer. Currently, lenvatinib and sorafenib are the approved drugs for the treatment of RAI-refractory DTC and PDTC while advanced MTC can be treated with either cabozantinib or vandetanib. Dabrafenib plus trametinib is the only approved treatment by FDA for BRAFV600E mutated ATC. A new generation of TKIs, specifically for single altered oncogenes, is under evaluation in phase 2 and 3 clinical trials. The aim of this review was to provide an overview of the current and future treatments of thyroid cancer with regards to the advanced and progressive cases that require systemic therapies that are becoming more and more targeted on the molecular identity of the tumor.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy; (L.L.); (V.C.); (L.V.); (C.G.); (D.V.); (L.P.); (C.G.); (E.M.); (M.C.C.); (A.M.); (V.B.); (L.A.); (E.M.)
| |
Collapse
|
6
|
Abstract
The diagnostic modalities, stratification tools, and treatment options for patients with thyroid cancer have rapidly evolved since the development of the American Thyroid Association (ATA) guidelines in 2015. This review compiles newer concepts in diagnosis, stratification tools and treatment options for patients with differentiated thyroid cancer (DTC), medullary thyroid carcinoma (MTC) and anaplastic thyroid cancer (ATC). Newer developments apply precision medicine in thyroid cancer patients to avoid over-treatment in low risk disease and under-treatment in high risk disease. Among novel patient-tailored therapies are selective RET inhibitors that have shown efficacy in the treatment of MTC with limited systemic toxicity compared with non-specific tyrosine kinase inhibitors. The combination of BRAF and MEK inhibitors have revolutionized management of BRAF V600E mutant ATC. Several immunotherapeutic agents are being actively investigated in the treatment of all forms of thyroid cancer. In this review, we describe the recent advances in the diagnosis and management of DTC, MTC, and ATC, with an emphasis on novel treatment modalities.
Collapse
Affiliation(s)
- Katherine A. Araque
- Endocrinology Department, Pacific Neuroscience Institute, John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Sriram Gubbi
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health (NIH), Bethesda, MD, USA
| |
Collapse
|
7
|
Thakur S, Tobey A, Klubo-Gwiezdzinska J. The Role of Lithium in Management of Endocrine Tumors-A Comprehensive Review. Front Oncol 2019; 9:1092. [PMID: 31750236 PMCID: PMC6842984 DOI: 10.3389/fonc.2019.01092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/04/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Epidemiological data reveal that treatment with lithium, a mood stabilizer, is associated with decreased incidence and mortality of certain cancer types, such as melanoma. Therefore, repositioning of lithium as an anticancer agent has emerged as a promising strategy in oncology. Since lithium affects the physiology of several endocrine tissues, the goal of this study was to analyze the role of lithium in the pathogenesis and treatment of tumors of the endocrine system. Methods: The databases of PubMed, EMBASE, MEDLINE, were searched from January 1970 through February 2019 for articles including the keywords "lithium and"-"thyroid cancer," "thyroid nodule," "parathyroid adenoma," "parathyroid carcinoma," "pituitary adenoma," "pituitary neuroendocrine tumor," "neuroendocrine tumor," "carcinoid," "adrenal adenoma," "adrenal carcinoma," "pheochromocytoma/paraganglioma." Preclinical in vitro and in vivo studies as well as case series, retrospective cohort studies and prospective trials were selected for the analysis. Results: Treatment with lithium has been associated with a higher prevalence of thyroid enlargement, hypothyroidism and increased calcium levels due to parathyroid adenoma or hyperplasia, as one of the mechanisms of its action is to stimulate proliferation of normal follicular thyroid and parathyroid cells via activation of the Wnt signaling pathway. Supratherapeutic concentrations of lithium decrease the activity of glycogen synthase kinase-3β (GSK-3β), leading to cell cycle arrest in several in vitro cancer models including medullary thyroid cancer (TC), pheochromocytoma/paraganglioma and carcinoid. Growth inhibitory effects of lithium in vivo have been documented in medullary TC xenograft mouse models. Clinically, lithium has been used as an adjuvant agent to therapy with radioactive iodine (RAI), as it increases the residence time of RAI in TC. Conclusion: Patients chronically treated with lithium need to be screened for hypothyroidism, goiter, and hyperparathyroidism, as the prevalence of these endocrine abnormalities is higher in lithium-treated patients than in the general population. The growth inhibitory effects of lithium in medullary TC, pheochromocytoma/paraganglioma and carcinoid were achieved with supratherapeutic concentrations of lithium thus limiting its translational perspective. Currently available clinical data on the efficacy of lithium in the therapy of endocrine tumors in human is limited and associated with conflicting results.
Collapse
Affiliation(s)
- Shilpa Thakur
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Andrew Tobey
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Joanna Klubo-Gwiezdzinska
- Metabolic Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
| |
Collapse
|
8
|
Brown SR, Hall A, Buckley HL, Flanagan L, Gonzalez de Castro D, Farnell K, Moss L, Gregory R, Newbold K, Du Y, Flux G, Wadsley J. Investigating the potential clinical benefit of Selumetinib in resensitising advanced iodine refractory differentiated thyroid cancer to radioiodine therapy (SEL-I-METRY): protocol for a multicentre UK single arm phase II trial. BMC Cancer 2019; 19:582. [PMID: 31200667 PMCID: PMC6567392 DOI: 10.1186/s12885-019-5541-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Thyroid cancer is the most common endocrine malignancy. Some advanced disease is, or becomes, resistant to radioactive iodine therapy (refractory disease); this holds poor prognosis of 10% 10-year overall survival. Whilst Sorafenib and Lenvatinib are now licenced for the treatment of progressive iodine refractory thyroid cancer, these treatments require continuing treatment and can be associated with significant toxicity. Evidence from a pilot study has demonstrated feasibility of Selumetinib to allow the reintroduction of I-131 therapy; this larger, multicentre study is required to demonstrate the broader clinical impact of this approach before progression to a confirmatory trial. METHODS SEL-I-METRY is a UK, single-arm, multi-centre, two-stage phase II trial. Participants with locally advanced or metastatic differentiated thyroid cancer with at least one measureable lesion and iodine refractory disease will be recruited from eight NHS Hospitals and treated with four-weeks of oral Selumetinib and assessed for sufficient I-123 uptake (defined as any uptake in a lesion with no previous uptake or 30% or greater increase in uptake). Those with sufficient uptake will be treated with I-131 and followed for clinical outcomes. Radiation absorbed doses will be predicted from I-123 SPECT/CT and verified from scans following the therapy. Sixty patients will be recruited to assess the primary objective of whether the treatment schedule leads to increased progression-free survival compared to historical control data. DISCUSSION The SEL-I-METRY trial will investigate the effect of Selumetinib followed by I-131 therapy on progression-free survival in radioiodine refractory patients with differentiated thyroid cancer showing increased radioiodine uptake following initial treatment with Selumetinib. In addition, information on toxicity and dosimetry will be collected. This study presents an unprecedented opportunity to investigate the role of lesional dosimetry in molecular radiotherapy, leading to greater personalisation of therapy. To date this has been a neglected area of research. The findings of this trial will be useful to healthcare professionals and patients alike to determine whether further study of this agent is warranted. It is hoped that the development of the infrastructure to deliver a multicentre trial involving molecular radiotherapy dosimetry will lead to further trials in this field. TRIAL REGISTRATION SEL-I-METRY is registered under ISRCTN17468602 , 02/12/2015.
Collapse
Affiliation(s)
- Sarah R. Brown
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, LS2 9JT UK
| | - Andrew Hall
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, LS2 9JT UK
| | - Hannah L. Buckley
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, LS2 9JT UK
| | - Louise Flanagan
- Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, LS2 9JT UK
| | - David Gonzalez de Castro
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, BT9 7BL Northern Ireland, UK
| | - Kate Farnell
- Butterfly Thyroid Cancer Trust, NCCC Freeman Hospital, Newcastle, NE39 2PU UK
| | - Laura Moss
- Velindre Cancer Centre, Cardiff, CF14 2TL UK
| | - Rebecca Gregory
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, SM2 5PT UK
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust, Sutton, SM2 5PT UK
| | - Yong Du
- Department of Nuclear Medicine, The Royal Marsden NHS Foundation Trust, Sutton, SM2 5PT UK
| | - Glenn Flux
- Joint Department of Physics, The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, SM2 5PT UK
| | | |
Collapse
|
9
|
Kim J, Song J, Ji HD, Yoo EK, Lee JE, Lee SB, Oh JM, Lee S, Hwang JS, Yoon H, Kim DS, Lee SJ, Jeong M, Lee S, Kim KH, Choi HS, Lee SW, Park KG, Lee IK, Kim SH, Hwang H, Jeon YH, Chin J, Cho SJ. Discovery of Potent, Selective, and Orally Bioavailable Estrogen-Related Receptor-γ Inverse Agonists To Restore the Sodium Iodide Symporter Function in Anaplastic Thyroid Cancer. J Med Chem 2019; 62:1837-1858. [DOI: 10.1021/acs.jmedchem.8b01296] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Jina Kim
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Jaeyoung Song
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | | | | | - Jae-Eon Lee
- Department of Biomaterials Science, College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Pusan 50463, South Korea
| | - Sang Bong Lee
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | | | | | - Ji Sun Hwang
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Heeseok Yoon
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Dong-Su Kim
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Su-Jeong Lee
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Minseon Jeong
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Sungwoo Lee
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Kyung-Hee Kim
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Hueng-Sik Choi
- National Creative Research Initiatives Center for Nuclear Receptor Signals and Hormone Research Center, School of Biological Sciences and Technology, Chonnam National University, Gwangju 61186, South Korea
| | | | - Keun-Gyu Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - In-Kyu Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, South Korea
| | - Seong Heon Kim
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Hayoung Hwang
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Yong Hyun Jeon
- Laboratory Animal Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Jungwook Chin
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| | - Sung Jin Cho
- New Drug Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu 41061, South Korea
| |
Collapse
|
10
|
Luo H, Tobey A, Auh S, Cochran C, Zemskova M, Reynolds J, Lima C, Burman K, Wartofsky L, Skarulis M, Kebebew E, Klubo-Gwiezdzinska J. The effect of lithium on the progression-free and overall survival in patients with metastatic differentiated thyroid cancer undergoing radioactive iodine therapy. Clin Endocrinol (Oxf) 2018; 89:481-488. [PMID: 29972703 PMCID: PMC6138537 DOI: 10.1111/cen.13806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/13/2018] [Accepted: 07/02/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pretreatment with lithium (Li) is associated with an increased residence time of radioactive iodine (RAI) in differentiated thyroid cancer (DTC) metastases. There are no data translating this observation into long-term outcomes. The study goal was to compare the efficacy of three methods of preparation for RAI therapy in metastatic DTC-thyroid hormone withdrawal (THW), THW with pretreatment with Li (THW+Li), and recombinant human TSH (rhTSH). DESIGN/PATIENTS/MEASUREMENTS We performed a cohort study comparing overall survival (OS) and progression-free survival (PFS) between the three groups: THW (n = 52), THW+Li (n = 41) and rhTSH (n = 42). Kaplan-Meier analyses were performed to compare OS and PFS between the groups. Cox proportional hazards regression model with a stepwise variable selection was performed to study the contribution of age, gender, histology, TNM status, a location of distant metastases and RAI dose. RESULTS During the follow-up of median 5.1 (IQR = 3.0-8.1) years, 52% of patients had disease progression and 12.6% died. Although THW+Li group was characterized by the longest OS (P = 0.007), only age (HR 1.05, CI 1.01-1.09, P = 0.01) and widespread disease (HR 3.8, CI 1.2-11.8, P = 0.02) were found to affect OS in a multivariate model. There was no difference in PFS between the groups (P = 0.47). Presence of distant metastases limited to the lungs only was associated with longer PFS (PFS HR 0.35, CI 0.20-0.60, P = 0.0002). CONCLUSION The older age is associated with shorter OS, while disease burden affects OS and PFS in patients with metastatic thyroid cancer. The method of preparation for RAI therapy does not affect the outcome.
Collapse
Affiliation(s)
- Hongxiu Luo
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Andrew Tobey
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Craig Cochran
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Marina Zemskova
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - James Reynolds
- Radiology and Imaging Sciences Department, NIH Clinical Center, Washigton, DC
| | - Cristiane Lima
- Endocrine Section, Medstar Washington Hospital Center, Washigton, DC
| | - Kenneth Burman
- Endocrine Section, Medstar Washington Hospital Center, Washigton, DC
| | - Leonard Wartofsky
- Endocrine Section, Medstar Washington Hospital Center, Washigton, DC
| | - Monica Skarulis
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Electron Kebebew
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| |
Collapse
|
11
|
Kreissl MC, Janssen MJR, Nagarajah J. Current Treatment Strategies in Metastasized Differentiated Thyroid Cancer. J Nucl Med 2018; 60:9-15. [PMID: 30190306 DOI: 10.2967/jnumed.117.190819] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/05/2018] [Indexed: 12/21/2022] Open
Abstract
On successful completion of this activity one should be able to judge the prognosis of patients harboring metastasized differentiated thyroid cancer (DTC); identify suitable treatment regimens, taking into account the characteristics of the tumor and the patient's general condition; and know the basics of radioiodine treatment, tyrosine kinase treatment, and redifferentiation treatment for metastasized DTC.
Collapse
Affiliation(s)
- Michael C Kreissl
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Marcel J R Janssen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; and .,Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
| |
Collapse
|
12
|
Tesselaar MH, Smit JW, Nagarajah J, Netea-Maier RT, Plantinga TS. Pathological processes and therapeutic advances in radioiodide refractory thyroid cancer. J Mol Endocrinol 2017; 59:R141-R154. [PMID: 28931558 DOI: 10.1530/jme-17-0134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 12/19/2022]
Abstract
While in most patients with non-medullary thyroid cancer (TC), disease remission is achieved by thyroidectomy and ablation of tumor remnants by radioactive iodide (RAI), a substantial subgroup of patients with metastatic disease present tumor lesions that have acquired RAI resistance as a result of dedifferentiation. Although oncogenic mutations in BRAF, TERT promoter and TP53 are associated with an increased propensity for induction of dedifferentiation, the role of genetic and epigenetic aberrations and their effects on important intracellular signaling pathways is not yet fully elucidated. Also immune, metabolic, stemness and microRNA pathways have emerged as important determinants of TC dedifferentiation and RAI resistance. These signaling pathways have major clinical implications since their targeting could inhibit TC progression and could enable redifferentiation to restore RAI sensitivity. In this review, we discuss the current insights into the pathological processes conferring dedifferentiation and RAI resistance in TC and elaborate on novel advances in diagnostics and therapy to improve the clinical outcome of RAI-refractory TC patients.
Collapse
Affiliation(s)
- Marika H Tesselaar
- Department of PathologyRadboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes W Smit
- Internal MedicineDivision of Endocrinology Radboud University Medical Center, Nijmegen, The Netherlands
| | - James Nagarajah
- Radiology & Nuclear MedicineRadboud University Medical Center, Nijmegen, The Netherlands
| | - Romana T Netea-Maier
- Internal MedicineDivision of Endocrinology Radboud University Medical Center, Nijmegen, The Netherlands
| | - Theo S Plantinga
- Department of PathologyRadboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
13
|
Amit M, Na'ara S, Francis D, Matanis W, Zolotov S, Eisenhaber B, Eisenhaber F, Weiler Sagie M, Malkin L, Billan S, Charas T, Gil Z. Post-translational Regulation of Radioactive Iodine Therapy Response in Papillary Thyroid Carcinoma. J Natl Cancer Inst 2017; 109:4108088. [DOI: 10.1093/jnci/djx092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 04/20/2017] [Indexed: 02/06/2023] Open
|
14
|
Newbold KL, Flux G, Wadsley J. Radioiodine for High Risk and Radioiodine Refractory Thyroid Cancer: Current Concepts in Management. Clin Oncol (R Coll Radiol) 2017; 29:307-309. [PMID: 28139379 DOI: 10.1016/j.clon.2016.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 12/13/2016] [Indexed: 11/15/2022]
Abstract
The management of early stage differentiated thyroid cancer (DTC) with low risk of recurrence has been the subject of much interest and investigation in the recent years. Locally advanced DTC and patients with a high risk of recurrent disease however needs further investigation. This short review will look at what constitutes high risk thyroid cancer, the definition of radioiodine refractory disease, the current management and areas of debate within this clinical setting.
Collapse
Affiliation(s)
- K L Newbold
- Department of Clinical Oncology, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK.
| | - G Flux
- Department of Medical Physics, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - J Wadsley
- Department of Clinical Oncology, Weston Park Hospital, Sheffield Teaching Hospitals Trust, Sheffield, UK
| |
Collapse
|
15
|
Bikas A, Vachhani S, Jensen K, Vasko V, Burman KD. Targeted therapies in thyroid cancer: an extensive review of the literature. Expert Rev Clin Pharmacol 2016; 9:1299-1313. [PMID: 27367142 DOI: 10.1080/17512433.2016.1204230] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Patients with progressive, metastatic, RAI-refractory differentiated thyroid cancer (DTC), as well as patients with advanced medullary (MTC) and anaplastic thyroid cancer represent a cohort for which therapeutic options are limited. The recent discoveries in the molecular mechanisms implicated in TC have provided insight of the pathogenesis and progression of disease. In that respect, targeted therapies have emerged as a promising alternative for the treatment of those patients. Areas covered: Tyrosine Kinase Inhibitors (TKIs) have been studied extensively in TC: sorafenib and lenvatinib have been approved by the FDA for the treatment of metastatic, RAI-refractory DTC, while vandetanib and cabozantinib are FDA approved for use in advanced MTC. Moreover, several additional TKIs, multi-targeted or specific, are currently under investigation in TC. The current manuscript provides an extensive review of the literature regarding targeted therapies in TC including the rationale behind their use, the clinical trials and an expert opinion on their use. Literature in English appearing at PubMed was thoroughly reviewed, especially manuscripts of the last 5 years. Expert commentary: Patients with advanced, progressive, metastatic TC should be evaluated for enrollment in a clinical trial or should be placed on treatment with one of the FDA- and EMA- approved agents.
Collapse
Affiliation(s)
- Athanasios Bikas
- a Division of Endocrinology, Department of Medicine , MedStar Washington Hospital Center , Washington , DC , USA
| | - Shivangi Vachhani
- a Division of Endocrinology, Department of Medicine , MedStar Washington Hospital Center , Washington , DC , USA
| | - Kirk Jensen
- b Department of Pediatrics , Uniformed Services University of the Health Sciences , Bethesda , MD , USA
| | - Vasyl Vasko
- b Department of Pediatrics , Uniformed Services University of the Health Sciences , Bethesda , MD , USA
| | - Kenneth D Burman
- a Division of Endocrinology, Department of Medicine , MedStar Washington Hospital Center , Washington , DC , USA
| |
Collapse
|
16
|
Yi KH, Lee EK, Kang HC, Koh Y, Kim SW, Kim IJ, Na DG, Nam KH, Park SY, Park JW, Bae SK, Baek SK, Baek JH, Lee BJ, Chung KW, Jung YS, Cheon GJ, Kim WB, Chung JH, Rho YS. 2016 Revised Korean Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Thyroid Cancer. ACTA ACUST UNITED AC 2016. [DOI: 10.11106/ijt.2016.9.2.59] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Ka Hee Yi
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Korea
| | - Eun Kyung Lee
- Department of Internal Medicine, Center for Thyroid Cancer, National Cancer Center, Korea
| | - Ho-Cheol Kang
- Department of Internal Medicine, Chonnam National University Medical School, Korea
| | - Yunwoo Koh
- Department of Otorhinolaryngology, College of Medicine, Yonsei University, Korea
| | - Sun Wook Kim
- Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - In Joo Kim
- Department of Internal Medicine, College of Medicine, Pusan National University, Korea
| | - Dong Gyu Na
- Department of Radiology, Human Medical Imaging and Intervention Center, Korea
| | - Kee-Hyun Nam
- Department of Surgery, College of Medicine, Yonsei University, Korea
| | - So Yeon Park
- Department of Pathology, Seoul National University College of Medicine, Korea
| | - Jin Woo Park
- Department of Surgery, College of Medicine, Chungbuk National University, Korea
| | - Sang Kyun Bae
- Department of Nuclear Medicine, Inje University College of Medicine, Korea
| | - Seung-Kuk Baek
- Department of Otorhinolaryngology, College of Medicine, Korea University, Korea
| | - Jung Hwan Baek
- Department of Radiology, University of Ulsan College of Medicine, Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology, College of Medicine, Pusan National University, Korea
| | - Ki-Wook Chung
- Department of Surgery, University of Ulsan College of Medicine, Korea
| | - Yuh-Seog Jung
- Department of Otorhinolaryngology, Center for Thyroid Cancer, National Cancer Center, Korea
| | - Gi Jeong Cheon
- Department of Nuclear Medicine, Seoul National University College of Medicine, Korea
| | - Won Bae Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Korea
| | - Jae Hoon Chung
- Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea
| | - Young-Soo Rho
- Department of Otorhinolaryngology, Hallym University College of Medicine, Korea
| |
Collapse
|
17
|
Láinez MMNP, de Fuentes MAM, de la Torre Casares ML, Elvira JML. Addition of Lithium to Radioactive Iodine Treatment With Improved Response in a Woman With Progressive Papillary Thyroid Carcinoma. AACE Clin Case Rep 2016. [DOI: 10.4158/ep15654.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
18
|
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: 8446] [Impact Index Per Article: 1055.8] [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.
Collapse
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
| | | | | | | |
Collapse
|
19
|
Abeillon-du Payrat J, Caron P, Borson-Chazot F. [What's new in follicular thyroid cancer management in 2014?]. ANNALES D'ENDOCRINOLOGIE 2015; 75 Suppl 1:S2-12. [PMID: 25617919 DOI: 10.1016/s0003-4266(14)70022-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Thyroid Association has presented new guidelines for the management of thyroid cancer. These guidelines tend to appreciate more accurately the individual risk of patients, to adapt accordingly the treatment and the follow up. The initial risk stratification has been completed, especially precising the risk of N1 patients, follicular thyroid cancers, and the prognostic impact of molecular markers. Indications, doses and modalities of radioiodine (RAI) have been reevaluated, restricting its utilization in order to avoid overtreatment of low risk patients. Moreover the response to initial treatment allows to restratify the risk of the patients, and to adapt the monitoring and the thyroid hormone therapy management. The risk of suppressive thyroid hormone therapy has also to be considered. Concerning advanced thyroid cancer, prognosis is mainly depending on its RAI sensitivity. The systemic treatment of progressive, threatening refractory cancers is nowadays based on targeted therapy. However none of these treatments has demonstrated an improvement in overall survival, and side effects are frequent. Fagin et al presented promising results concerning short term treatment with selective inhibitors of the MAPK pathway, able to partially restore RAI sensitivity of refractory lesions in murine models, and recently in human patients.
Collapse
Affiliation(s)
- J Abeillon-du Payrat
- Hospices civils de Lyon, fédération d'endocrinologie, groupement hospitalier Est, 59, boulevard Pinel, 69677 Bron, Cedex, France; Université Lyon 1, faculté de médecine Lyon-Est, Lyon, France.
| | - P Caron
- Service d'endocrinologie et maladies métaboliques, Pôle cardiovasculaire et métabolique, hôpital Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse, Cedex 9, France
| | - F Borson-Chazot
- Hospices civils de Lyon, fédération d'endocrinologie, groupement hospitalier Est, 59, boulevard Pinel, 69677 Bron, Cedex, France; Université Lyon 1, faculté de médecine Lyon-Est, Lyon, France; INSERM U1052, centre de recherche en cancérologie, Lyon-Est, centre Léon-Bérard, bâtiment Cheney D, 28, rue Laënnec, 69373 Lyon, Cedex 08, France
| |
Collapse
|
20
|
Carneiro RM, Carneiro BA, Agulnik M, Kopp PA, Giles FJ. Targeted therapies in advanced differentiated thyroid cancer. Cancer Treat Rev 2015; 41:690-8. [PMID: 26105190 DOI: 10.1016/j.ctrv.2015.06.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/09/2015] [Accepted: 06/10/2015] [Indexed: 12/12/2022]
Abstract
Differentiated thyroid cancer is the most common endocrine malignancy, and its incidence has been rising rapidly over the past 10 years. Although most patients with this disease have an excellent prognosis, a subset develops a more aggressive disease phenotype refractory to conventional therapies. Until recently, there was no effective therapy for these patients. With increasing knowledge of the molecular pathogenesis of thyroid cancer, novel targeted therapies are being developed for this group of patients. Sorafenib and lenvatinib, small-molecule multikinase inhibitors, were approved for the treatment of progressive, symptomatic, radioactive iodine refractory, advanced differentiated thyroid cancer in 2013 and 2015, respectively. This represents a major innovation in the therapy of patients with advanced thyroid cancer. However, these therapies still have many limitations and further research needs to be pursued with the ultimate goal of providing safe and effective personalized therapy for patients with advanced thyroid cancer.
Collapse
Affiliation(s)
- Raquel M Carneiro
- Northwestern Medicine Developmental Therapeutics Institute, Northwestern University, United States; Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, United States; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States.
| | - Benedito A Carneiro
- Northwestern Medicine Developmental Therapeutics Institute, Northwestern University, United States; Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, United States; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States.
| | - Mark Agulnik
- Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, United States; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States.
| | - Peter A Kopp
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, United States; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States.
| | - Francis J Giles
- Northwestern Medicine Developmental Therapeutics Institute, Northwestern University, United States; Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, United States; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, United States.
| |
Collapse
|
21
|
Ruan M, Liu M, Dong Q, Chen L. Iodide- and glucose-handling gene expression regulated by sorafenib or cabozantinib in papillary thyroid cancer. J Clin Endocrinol Metab 2015; 100:1771-9. [PMID: 25768669 DOI: 10.1210/jc.2014-3023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The aberrant silencing of iodide-handling genes accompanied by up-regulation of glucose metabolism presents a major challenge for radioiodine treatment of papillary thyroid cancer (PTC). OBJECTIVE This study aimed to evaluate the effect of tyrosine kinase inhibitors on iodide-handling and glucose-handling gene expression in BHP 2-7 cells harboring RET/PTC1 rearrangement. MAIN OUTCOME MEASURES In this in vitro study, the effects of sorafenib or cabozantinib on cell growth, cycles, and apoptosis were investigated by cell proliferation assay, cell cycle analysis, and Annexin V-FITC apoptosis assay, respectively. The effect of both agents on signal transduction pathways was evaluated using the Western blot. Quantitative real-time PCR, Western blot, immunofluorescence, and radioisotope uptake assays were used to assess iodide-handling and glucose-handling gene expression. RESULTS Both compounds inhibited cell proliferation in a time-dependent and dose-dependent manner and caused cell cycle arrest in the G0/G1 phase. Sorafenib blocked RET, AKT, and ERK1/2 phosphorylation, whereas cabozantinib blocked RET and AKT phosphorylation. The restoration of iodide-handling gene expression and inhibition of glucose transporter 1 and 3 expression could be induced by either drug. The robust expression of sodium/iodide symporter induced by either agent was confirmed, and (125)I uptake was correspondingly enhanced. (18)F-fluorodeoxyglucose accumulation was significantly decreased after treatment by either sorafenib or cabozantinib. CONCLUSIONS Sorafenib and cabozantinib had marked effects on cell proliferation, cell cycle arrest, and signal transduction pathways in PTC cells harboring RET/PTC1 rearrangement. Both agents could be potentially used to enhance the expression of iodide-handling genes and inhibit the expression of glucose transporter genes.
Collapse
Affiliation(s)
- Maomei Ruan
- Department of Nuclear Medicine (M.R., M.L., L.C.), Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; and Section of Cancer Stem Cells (Q.D.), Shanghai Cancer Institute, Shanghai Jiao Tong University, Shanghai 200032, China
| | | | | | | |
Collapse
|
22
|
Marotta V, Sciammarella C, Vitale M, Colao A, Faggiano A. The evolving field of kinase inhibitors in thyroid cancer. Crit Rev Oncol Hematol 2015; 93:60-73. [DOI: 10.1016/j.critrevonc.2014.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/15/2014] [Accepted: 08/19/2014] [Indexed: 01/04/2023] Open
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Several new targeted therapies with multikinase inhibitors targeting vascular endothelial growth factor (VEGF), rearranged during transfection and v-raf murine sarcoma viral oncogene homolog B1 pathways have been tested in clinical trials for radioiodine-refractory differentiated thyroid cancer (DTC) and medullary thyroid cancer (MTC) in the past 10 years. RECENT FINDINGS Results of the first phase III trial of VEGF-targeted therapy (sorafenib) in DTC were presented in June 2013, and two phase III trials with VEGF and rearranged during transfection-targeted therapies (vandetanib and cabozantinib) in MTC have led to approval by US Food and Drug Administration in the past 2 years. Whereas such therapies increase median progression-free survival compared to placebo, there is no therapy proven to improve overall survival yet. Significant potential adverse event risks associated with such therapies need to be recognized. Dissemination of knowledge about targeted therapies is critical for various medical specialists as patient care for thyroid cancers is best delivered in a multidisciplinary setting. SUMMARY Successful development of targeted systemic therapies in DTC and MTC in the past 5 years is incredibly exciting in the field and patients with advanced DTC/MTC now have new standard-of-care therapy options.
Collapse
|
25
|
Abstract
Since chemotherapy has been shown to be unsuccessful in case of advanced thyroid carcinomas, the research for new therapies is fundamental. Clinical trials of many tyrosine kinase inhibitors as well as anti-angiogenic inhibitors suggest that patients with thyroid cancer could have an advantage with new target therapy. Recently, Food and Drug Administration approved two targeted therapies, vandetanib and cabozantinib for the treatment of metastatic thyroid carcinomas with acceptable outcome. We summarized the results and the toxic effects associated with these treatments reported in clinical trials. Future trials should aim at combinations of targeted agents with or without other treatment modalities to obtain a more effective result in thyroid carcinoma treatment.
Collapse
|
26
|
Fröhlich E, Wahl R. The current role of targeted therapies to induce radioiodine uptake in thyroid cancer. Cancer Treat Rev 2014; 40:665-74. [DOI: 10.1016/j.ctrv.2014.01.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 01/11/2014] [Accepted: 01/13/2014] [Indexed: 12/18/2022]
|
27
|
Leboulleux S, Déandreis D, Lumbroso J, Baudin E, Schlumberger M. Cancers de la thyroïde et traitement par iode 131. MEDECINE NUCLEAIRE-IMAGERIE FONCTIONNELLE ET METABOLIQUE 2014. [DOI: 10.1016/j.mednuc.2014.03.132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
28
|
Ho AL, Grewal RK, Leboeuf R, Sherman EJ, Pfister DG, Deandreis D, Pentlow KS, Zanzonico PB, Haque S, Gavane S, Ghossein RA, Ricarte-Filho JC, Domínguez JM, Shen R, Tuttle RM, Larson SM, Fagin JA. Selumetinib-enhanced radioiodine uptake in advanced thyroid cancer. N Engl J Med 2013; 368:623-32. [PMID: 23406027 PMCID: PMC3615415 DOI: 10.1056/nejmoa1209288] [Citation(s) in RCA: 536] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metastatic thyroid cancers that are refractory to radioiodine (iodine-131) are associated with a poor prognosis. In mouse models of thyroid cancer, selective mitogen-activated protein kinase (MAPK) pathway antagonists increase the expression of the sodium-iodide symporter and uptake of iodine. Their effects in humans are not known. METHODS We conducted a study to determine whether the MAPK kinase (MEK) 1 and MEK2 inhibitor selumetinib (AZD6244, ARRY-142886) could reverse refractoriness to radioiodine in patients with metastatic thyroid cancer. After stimulation with thyrotropin alfa, dosimetry with iodine-124 positron-emission tomography (PET) was performed before and 4 weeks after treatment with selumetinib (75 mg twice daily). If the second iodine-124 PET study indicated that a dose of iodine-131 of 2000 cGy or more could be delivered to the metastatic lesion or lesions, therapeutic radioiodine was administered while the patient was receiving selumetinib. RESULTS Of 24 patients screened for the study, 20 could be evaluated. The median age was 61 years (range, 44 to 77), and 11 patients were men. Nine patients had tumors with BRAF mutations, and 5 patients had tumors with mutations of NRAS. Selumetinib increased the uptake of iodine-124 in 12 of the 20 patients (4 of 9 patients with BRAF mutations and 5 of 5 patients with NRAS mutations). Eight of these 12 patients reached the dosimetry threshold for radioiodine therapy, including all 5 patients with NRAS mutations. Of the 8 patients treated with radioiodine, 5 had confirmed partial responses and 3 had stable disease; all patients had decreases in serum thyroglobulin levels (mean reduction, 89%). No toxic effects of grade 3 or higher attributable by the investigators to selumetinib were observed. One patient received a diagnosis of myelodysplastic syndrome more than 51 weeks after radioiodine treatment, with progression to acute leukemia. CONCLUSIONS Selumetinib produces clinically meaningful increases in iodine uptake and retention in a subgroup of patients with thyroid cancer that is refractory to radioiodine; the effectiveness may be greater in patients with RAS-mutant disease. (Funded by the American Thyroid Association and others; ClinicalTrials.gov number, NCT00970359.).
Collapse
Affiliation(s)
- Alan L Ho
- Head and Neck Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY 10065, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Review of the management decisions that must be made by the endocrinologist during the use of radioactive iodine (RAI) therapy of hyperthyroidism and differentiated thyroid cancer. RECENT FINDINGS Since the 1940s radioactive (131)I (RAI) therapy has been a major component of the treatment of hyperthyroidism and differentiated thyroid cancer. RAI is the most common definitive treatment of hyperthyroidism. Pretherapy decisions including use of antithyroid medication and low-iodine diet will be discussed with the relevant supportive literature. The method of semi-quantitative calculation used for RAI treatment of hyperthyroidism will be described. Evidence-based guideline for the management of differentiated thyroid cancer by the American Thyroid Association, new drug development and recent randomized controlled trials have changed current practice of how RAI is used for remnant ablation and adjuvant therapy of differentiated thyroid cancer. SUMMARY RAI is a common tool for the endocrinologist in the management of hyperthyroidism and differentiated thyroid cancer. Review of the management decisions and practice of RAI therapy will educate the endocrinologist of the literature supporting current RAI use in hyperthyroidism and new developments in limiting the radiation exposure to the patients with differentiated thyroid cancer.
Collapse
Affiliation(s)
- Stephanie L Lee
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts 02118, USA.
| |
Collapse
|
30
|
Kapiteijn E, Schneider TC, Morreau H, Gelderblom H, Nortier JWR, Smit JWA. New treatment modalities in advanced thyroid cancer. Ann Oncol 2012; 23:10-18. [PMID: 21471561 DOI: 10.1093/annonc/mdr117] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Thyroid cancer is a heterogeneous disease that is classified into differentiated thyroid carcinoma (DTC), undifferentiated/anaplastic thyroid carcinoma (ATC) and medullary thyroid carcinoma. Results of conventional treatment modalities in advanced thyroid cancer have been disappointing and therefore, new therapies are needed. METHODS We searched PubMed, The Cochrane Library, Medline and EMBASE databases and abstracts published in annual proceedings for new treatment modalities in advanced thyroid cancer. We also searched for ongoing trials in www.clinicaltrials.gov. RESULTS Six phase I, 17 phase II and 1 phase III trials with tyrosine kinase inhibitors were carried out. We found 2 pilot studies and 11 phase II trials with redifferentiation therapies, mainly in DTC. For antiproliferative approaches, three phase I and four phase II trials were found. Immunomodulatory gene therapy was tested in a pilot study in ATC patients. Two phase II trials were carried out with immunotherapy. One phase I and nine phase II trials were found with radionucleotide therapy in patients with DTC. CONCLUSION The developments in the treatment of advanced thyroid cancer are intriguing. Future trials should aim at combinations of targeted agents with or without other treatment modalities, and will hopefully contribute to further improvement of outcomes.
Collapse
Affiliation(s)
| | | | | | | | | | - J W A Smit
- Endocrinology and Metabolic Diseases, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
31
|
Konrády A, Bencsik Z, Locsey Z, Bénik T. [Outcome of differentiated thyroid cancer after initial treatment]. Orv Hetil 2011; 152:1731-8. [PMID: 21983399 DOI: 10.1556/oh.2011.29227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED Incidence of differentiated thyroid cancer has increased in the last two decades. This type of cancer is now being diagnosed at an earlier stage. Treatment strategy has been modified. AIMS The goals of this study were to analyze the outcome of differentiated thyroid cancer after initial treatment (surgery and radioiodine ablation) in patients evaluated and followed up in a single centre between l999 and 2009, to compare these results with others as well as to monitor the adoption of international recommendation. 107 patients having T1-T2 differentiated thyroid cancer were studied. Mean follow-up time was 63 months. RESULTS After surgery patients were prepared using thyroid hormone withdrawal or recombinant human thyrotropin, then 1.1-3.7 GBq 131-iodine was administered. First year evaluation consisted of ultrasound as well as serum thyrotropin and thyroglobulin (plus thyroglobulin antibody) determinations. Ablation success rate was 83% and the five year survival was 100%. There was not any cancer specific death. CONCLUSION In the future somewhat more radical surgery and less remnant ablation is needed with unified follow-up protocol.
Collapse
|
32
|
Tyrosine kinase inhibitors in differentiated thyroid carcinoma: a review of the clinical evidence. ACTA ACUST UNITED AC 2011. [DOI: 10.4155/cli.10.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
33
|
Hingorani M, Spitzweg C, Vassaux G, Newbold K, Melcher A, Pandha H, Vile R, Harrington K. The biology of the sodium iodide symporter and its potential for targeted gene delivery. Curr Cancer Drug Targets 2010; 10:242-67. [PMID: 20201784 DOI: 10.2174/156800910791054194] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 02/16/2010] [Indexed: 12/12/2022]
Abstract
The sodium iodide symporter (NIS) is responsible for thyroidal, salivary, gastric, intestinal and mammary iodide uptake. It was first cloned from the rat in 1996 and shortly thereafter from human and mouse tissue. In the intervening years, we have learned a great deal about the biology of NIS. Detailed knowledge of its genomic structure, transcriptional and post-transcriptional regulation and pharmacological modulation has underpinned the selection of NIS as an exciting approach for targeted gene delivery. A number of in vitro and in vivo studies have demonstrated the potential of using NIS gene therapy as a means of delivering highly conformal radiation doses selectively to tumours. This strategy is particularly attractive because it can be used with both diagnostic (99mTc, 125I, 124I)) and therapeutic (131I, 186Re, 188Re, 211At) radioisotopes and it lends itself to incorporation with standard treatment modalities, such as radiotherapy or chemoradiotherapy. In this article, we review the biology of NIS and discuss its development for gene therapy.
Collapse
Affiliation(s)
- Mohan Hingorani
- The Institute of Cancer Research, 237 Fulham Road, London SW36JB, UK
| | | | | | | | | | | | | | | |
Collapse
|
34
|
O'Neill CJ, Oucharek J, Learoyd D, Sidhu SB. Standard and emerging therapies for metastatic differentiated thyroid cancer. Oncologist 2010; 15:146-56. [PMID: 20142332 DOI: 10.1634/theoncologist.2009-0190] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Differentiated thyroid cancer accounts for >90% of cases of thyroid cancer, with most patients having an excellent prognosis. Distant metastases occur in 10%-15% of patients, decreasing the overall 10-year survival rate in this group to 40%. Radioactive iodine has been the mainstay of treatment for distant metastases, with good results when lesions retain the ability to take up iodine. For patients with metastatic disease resistant to radioactive iodine, treatment options are few and survival is poor. Chemotherapy and external beam radiotherapy have been used in these patients, but with disappointing results. In recent years, our understanding of the molecular pathways involved in thyroid cancer has increased and a number of molecular targets have been identified. These targets include the proto-oncogenes BRAF and RET, known to be common mutations in thyroid cancer; vascular endothelial growth factor receptor and platelet-derived growth factor receptor, associated with angiogenesis; and the sodium-iodide symporter, with the aim of restoring its expression and hence radioactive iodine uptake. There are now multiple trials of tyrosine kinase inhibitors, angiogenesis inhibitors, and other novel agents available to patients with metastatic thyroid cancer. This review discusses both traditional and novel treatments for metastatic differentiated thyroid cancer with a particular focus on emerging treatments for patients with radioactive iodine-refractory disease.
Collapse
Affiliation(s)
- Christine J O'Neill
- University of Sydney Endocrine Surgical Unit, St. Leonards, New South Wales, Australia
| | | | | | | |
Collapse
|
35
|
Abstract
One in 200 people receive lithium for treatment of bipolar disorder. The common clinical side effects of the drug are goitre in up to 40% and hypothyroidism in about 20%. Lithium increases thyroid autoimmunity if present before therapy. Treatment with levothyroxine is effective and lithium therapy should not be stopped. Lithium may cause hyperthyroidism due to thyroiditis or rarely Graves' disease. As lithium inhibits thyroid hormone release from the thyroid gland it can be used as an adjunct therapy in the management of severe hyperthyroidism. It also increases thyroidal radioiodine retention and may be effective in reducing administered activity in hyperthyroidism. There is no clinical benefit of lithium therapy in thyroid cancer. More research is required on the cellular proliferative effects of lithium as well as its impact on the immune system.
Collapse
Affiliation(s)
- John H Lazarus
- Centre for Endocrine and Diabetes Sciences, Cardiff University School of Medicine, University Hospital of Wales, Cardiff CF14 4 XN, Wales, UK.
| |
Collapse
|
36
|
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009; 19:1167-214. [PMID: 19860577 DOI: 10.1089/thy.2009.0110] [Citation(s) in RCA: 4626] [Impact Index Per Article: 308.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the publication of the American Thyroid Association's guidelines for the management of these disorders was published in 2006, a large amount of new information has become available, prompting a revision of the guidelines. METHODS Relevant articles through December 2008 were reviewed by the task force and categorized by topic and level of evidence according to a modified schema used by the United States Preventative Services Task Force. 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, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to optimal surgical management, radioiodine remnant ablation, and suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using ultrasound and serum thyroglobulin as well as those related to management of recurrent and metastatic disease. CONCLUSIONS We created evidence-based recommendations in response to our appointment as an independent task force by the American Thyroid Association to assist in the clinical management of patients with thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.
Collapse
|
37
|
Recombinant human TSH and ablation of post-surgical thyroid remnants in differentiated thyroid cancer: the effect of pre-treatment with furosemide and furosemide plus lithium. Eur J Nucl Med Mol Imaging 2009; 37:242-9. [DOI: 10.1007/s00259-009-1254-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 07/31/2009] [Indexed: 10/20/2022]
|
38
|
Reiners C, Dietlein M, Luster M. Radio-iodine therapy in differentiated thyroid cancer: indications and procedures. Best Pract Res Clin Endocrinol Metab 2008; 22:989-1007. [PMID: 19041827 DOI: 10.1016/j.beem.2008.09.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Post-surgical ablative iodine-131 therapy is recommended for all differentiated thyroid cancer primary tumors>1 cm in diameter. Regarding smaller primary tumors, 131I ablation may be helpful in special cases: tumor close to the thyroid capsule, previous percutaneous radiation to the neck, familial occurrence of thyroid cancer, tumor diameter 5-10 mm, and unfavorable histological variants. In this context, the patient's preferences for safety should be considered. In most centers, standard fixed activities of 1-3 GBq are used for 131I ablation. Preparation for the procedure with such activities requires a low-iodine diet for 2-3 weeks and stimulation of thyroid stimulating hormone (TSH) by withholding of thyroid hormone for 3 weeks following thyroidectomy or by use of recombinant human TSH. The advantages of recombinant TSH are avoidance of hypothyroid morbidity and consequently a better quality of life, as well as a lower radiation dose to extra-thyroidal compartments. To treat metastastic differentiated thyroid cancer, higher activities of radio-iodine (in the range 4-11 GBq) are necessary; if possible, individual dosimetry is recommended. The standard approach to preparation for 131I therapy in patients with metastases is endogenous hypothyroidism after thyroid hormone withdrawal.
Collapse
Affiliation(s)
- Christoph Reiners
- Department of Nuclear Medicine, University of Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
| | | | | |
Collapse
|
39
|
Li HR, Liu Y, Qin CQ, Li QG. Bioenergetic investigation of action of lithium to Tetrahymena thermophila bF5 by microcalorimetry. Biol Trace Elem Res 2007; 119:60-7. [PMID: 17914220 DOI: 10.1007/s12011-007-0040-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 11/30/1999] [Accepted: 03/12/2007] [Indexed: 11/27/2022]
Abstract
Microcalorimetry was employed to investigate the action of Li(I) to aquatic ecosystem from the point view of bioenergetics. Tetrahymena thermophila BF5 was chosen as the model organism. The power-time curves of T. thermophila BF5 growth metabolism in the absence and presence of Li(I) were obtained. The corresponding thermokinetic parameters were derived. The generation time was calculated as 592.3 min, which was consistent with the biomass values. Low concentration of Li(I) (1-20 mmol l-1) stimulated the growth of T. thermophila BF5, whereas the inhibition effect was observed in high concentration (30-100 mmol l-1). The value of IC50 was 52.8 mmol l-1. In the concentration range of 30-100 mmol l-1, the growth rate constants (k) and the maximum heat out power (P max) decrease with the concentration of Li(I), whereas the heat output (Q) increases slightly compared to the control. Other than the classic mechanism of inositol-phosphate cycle, the involvement of mitochondria mechanism was discussed and suggested.
Collapse
Affiliation(s)
- Hui-Rong Li
- College of Chemistry and Molecular Sciences, Wuhan University, Wuhan 430072, People's Republic of China
| | | | | | | |
Collapse
|
40
|
Maia AL, Ward LS, Carvalho GA, Graf H, Maciel RMB, Maciel LMZ, Rosário PW, Vaisman M. Nódulos de tireóide e câncer diferenciado de tireóide: consenso brasileiro. ACTA ACUST UNITED AC 2007; 51:867-93. [PMID: 17891253 DOI: 10.1590/s0004-27302007000500027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Accepted: 03/19/2007] [Indexed: 11/21/2022]
Abstract
Os nódulos tireoidianos constituem a principal manifestação clínica de uma série de doenças da tireóide com uma prevalência de aproximadamente 10% na população adulta. O maior desafio é excluir o câncer da tireóide, que ocorre em 5 a 10% dos casos. Os carcinomas diferenciados respondem por 90% dos casos de todas as neoplasias malignas da tireóide. A maioria dos pacientes com carcinoma diferenciado apresenta, geralmente, um bom prognóstico quando tratada adequadamente, com índices de mortalidade similares à população geral. No entanto, alguns indivíduos apresentam doença agressiva, desafiando o conhecimento atual e ilustrando a complexidade do manejo dessa neoplasia. No presente trabalho, reunimos 8 membros do Departamento de Tireóide da Sociedade Brasileira de Endocrinologia & Metabologia, para elaborarmos, por consenso, as diretrizes brasileiras no manejo dos nódulos tireoidianos e do câncer diferenciado da tireóide. Os membros participantes representam diferentes Centros Universitários do Brasil, refletindo diferentes abordagens diagnósticas e terapêuticas. Inicialmente, cada participante ficou responsável pela redação de determinado tema a ser enviado ao Coordenador, que, após revisão editorial e elaboração da primeira versão do manuscrito, enviou ao grupo para sugestões e aperfeiçoamentos. Quando concluído, o manuscrito foi novamente enviado e revisado por todos. A elaboração dessas diretrizes foi baseada na experiência dos participantes e revisão pertinente da literatura.
Collapse
Affiliation(s)
- Ana Luiza Maia
- Departamento de Tireóide, Sociedade Brasileira de Endocrinologia e Metabologia, Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Universidad Federal do Rio Grande do Sul, RS, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|