Outcome of differentiated thyroid cancer with detectable serum Tg and negative diagnostic (131)I whole body scan: comparison of patients treated with high (131)I activities versus untreated patients

Efficacy of Empirical 131I Radioiodine Therapy in Well-Differentiated Thyroid Carcinoma Patients With Thyroglobulin-Elevated Negative Iodine Scintigraphy Syndrome: A Systematic Review and Meta-analysis

OBJECTIVES

This study aimed to perform a systematic review and meta-analysis on the efficacy of empirical high-dose radioiodine therapy in treating differentiated thyroid cancer patients with thyroglobulin (Tg)-elevated negative iodine scintigraphy (TENIS) syndrome.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library to identify relevant studies published until April 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist and registered in an international prospective register of systematic reviews (PROSPERO). Meta-analyses of proportions and odds ratios were performed to assess the beneficial effect of empirical high-dose radioiodine therapy in patients with TENIS syndrome. Subgroup analysis was also performed according to the presence of micrometastasis or macrometastasis.

RESULTS

We identified 14 studies including 690 patients who received empirical high-dose radioiodine therapy for TENIS syndrome. Those who had micrometastasis exhibited additional lesions not previously observed on diagnostic whole-body scan (prop = 0.64, 95% confidence interval [CI], 0.51-0.77) and had reduced serum Tg levels (prop = 0.69; 95% CI, 0.52-0.84) after empirical radioiodine treatment. No such findings were observed among patients with macrometastasis. Moreover, we found that the empirical radioiodine treatment group had lower serum Tg levels than did controls (odds ratio = 0.27; 95% CI, 0.09-0.87), which suggests a lower risk of disease progression.

CONCLUSION

Our findings indicate that empirical high-dose radioiodine therapy promoted beneficial effects and could be recommended for patients with TENIS syndrome, especially those with micrometastasis.

Management of Recurrent Well-Differentiated Thyroid Carcinoma in the Neck: A Comprehensive Review

Surgery has been historically the preferred primary treatment for patients with well-differentiated thyroid carcinoma and for selected locoregional recurrences. Adjuvant therapy with radioactive iodine is typically recommended for patients with an intermediate to high risk of recurrence. Despite these treatments, locally advanced disease and locoregional relapses are not infrequent. These patients have a prolonged overall survival that may result in long periods of active disease and the possibility of requiring subsequent treatments. Recently, many new options have emerged as salvage therapies. This review offers a comprehensive discussion and considerations regarding surgery, active surveillance, radioactive iodine therapy, ultrasonography-guided percutaneous ablation, external beam radiotherapy, and systemic therapy for well-differentiated thyroid cancer based on relevant publications and current reference guidelines. We feel that the surgical member of the thyroid cancer management team is empowered by being aware and facile with all management options.

Active surveillance in differentiated thyroid cancer: a strategy applicable to all treatment categories response

Currently, the differentiated thyroid cancer (DTC) management is shifted toward a tailored approach based on the estimated risks of recurrence and disease-specific mortality. While the current recommendations on the management of metastatic and progressive DTC are clear and unambiguous, the management of slowly progressive or indeterminate disease varies according to different centers and different physicians. In this context, active surveillance (AS) becomes the main tool for clinicians, allowing them to plan a personalized therapeutic strategy, based on the risk of an unfavorable prognosis, and to avoid unnecessary treatment. This review analyzes the main possible scenarios in treated DTC patients who could take advantage of AS.

Applicability of Adults 2015 American Thyroid Association Differentiated Thyroid Cancer Guidelines for Postoperative Risk Stratification and Postradioiodine Treatment Dynamic Risk Stratification in Pediatric Population

Purpose  This retrospective study aimed to study the applicability of 2015 adult American Thyroid Association (ATA) differentiated thyroid cancer (DTC) postoperative risk stratification and guidelines in the pediatric population for evaluating the number of metastatic lymph nodes in the postoperative risk stratification and postradioactive iodine (RAI) treatment dynamic risk stratification (DRS) using response to treatment (RTT) reclassification. In addition, the effect of pubertal status and gender was assessed on disease presentation and prognosis.

Methods  Data of 63 DTC patients aged 20 years or less, stratified into prepubertal, pubertal, and postpubertal age groups, was divided into low, intermediate, and high-risk groups using pediatric ATA recurrence risk stratification. Forty-seven patients were classified as responders (excellent and indeterminate responses) and incomplete responders (biochemical and structurally incomplete responses) by assessing the RTT at 1.5 years follow-up similar to recommendation of 2015 adult DTC ATA guidelines.

Results  Female-to-male ratio showed a trend of gradual increase with increasing age. Significantly more responders were observed in low- and intermediate-risk groups than in high-risk group ( p  = 0.0013; p  = 0.017, respectively), while prepubertal group had more extensive (N1b) disease. Using DRS at follow-up of 1.5 year, pubertal and postpubertal groups showed significantly better response to RAI. More female than male patients showed response and took significantly less time to respond to RAI ( p  = 0.003).

Conclusion  RAI response in pediatric DTC depends on pubertal status, gender, and number of malignant nodes. DRS using RTT classification may be applicable early at 1.5 years after initial therapy in different pubertal age and risk groups.

Radioiodine adjuvant therapy in differentiated thyroid cancer: An update and reconsideration

Radioiodine (¹³¹I) therapy (RAI) has been utilized for treating differentiated thyroid cancer (DTC) for decades, and its uses can be characterized as remnant ablation, adjuvant therapy (RAT) or treatment for known diseases. Compared with the definite ¹³¹I treatment targets for remnant ablation and known disease, ¹³¹I adjuvant therapy (RAT) aims to reduce the risk of recurrence by destroying potential subclinical disease. Since it is merely given as a risk with no imaging confirmation of persistence/recurrence/metastases, the evidence is uncertain. With limited knowledge and substance, the indication for RAT remains poorly defined for everyday clinical practice, and the benefits of RAT remain controversial. This ambiguity results in a puzzle for clinicians seeking clarity on whether patients should receive RAT, and whether patients are at risk of recurrence/death from undertreatment or adverse events from overtreatment. Herein, we clarified the RAT indications in terms of clinicopathological features, postoperative disease status and response to therapy evaluation, and retrospectively examined the clinical outcomes of RAT as reported in current studies and guidelines. Furthermore, given the evolution of nuclear medicine imaging techniques, it can be expected that the future of RAT may be advanced by nuclear medicine theranostics (i.e., ¹³¹I whole-body scan, PET/CT) by accurately revealing the biological behaviors, as well as the underlying molecular background.

Clinicopathological features and outcome of thyroglobulin elevation and negative iodine scintigraphy (TENIS) patients with negative neck ultrasound: Experience from a thyroid carcinoma clinic in India

Management of differentiated thyroid carcinoma (DTC) patients with thyroglobulin (Tg) elevation and negative iodine scintigraphy (TENIS) and negative neck ultrasound scan causes considerable diagnostic and therapeutic dilemma, especially in resource-poor settings. The aim of this study was to evaluate clinicopathological features and outcome of TENIS patients with negative neck US attending a thyroid cancer clinic in India. From a DTC database of 722 containing 193 TENIS patients, subjects with negative neck US and negative Tg antibody (TgAb) were selected retrospectively and analyzed using appropriate statistical methods. The study group included 64 patients (male – 17, female – 47, mean age – 44.7 ± 12.8 years) with 54 papillary and 10 follicular thyroid carcinomas, American Thyroid Association (ATA) recurrence risk categorization (2009) – low – 16, intermediate – 28, and high – 2 0. Most of the patients became TENIS within 1 year of diagnosis with median Tg level of 6.5 ng/mL (1.2–996 ng/mL) and mean follow-up of 7.8 years. On follow-up, Tg dropped spontaneously in 27 patients, more among the low and intermediate-risk categories. For those with high or increasing Tg level, further imaging (fluorodeoxyglucose positron emission tomography/computed tomography) was done and 14 out of 18 were positive. Treatment included empiric radioactive iodine therapy-16, external beam radiation therapy (EBRT)-7, and lymph node dissection (LND)-10. A favorable outcome was seen in 36 patients and unfavorable in 28. Distant metastases were associated with unfavorable outcome and poor survival. Progression-free survival was significantly better in the Tg group of <10 at the time of TENIS (111 months) compared to the Tg group >10 (72 months). Tg level dropped spontaneously in nearly half the patients, especially if levels were <10 and more so among the low-risk category. Distant metastasis was predictive of unfavorable outcomes. Along with Tg level, the ATA risk category might help to predict clinical course and reduce unnecessary expensive imaging in resource-poor settings.

High thyroglobulin and negative whole-body scan: no long-term benefit of empiric radioiodine therapy

PURPOSE

Around 10-27% of patients will present elevated thyroglobulin (Tg) levels and negative diagnostic whole-body scan (dxWBS) during differentiated thyroid cancer (DTC) follow-up. Empiric radioactive iodine (RAI) therapy in this context is controversial due to the lack of good quality studies in the context. The main purpose of this study is to compare long-term response to therapy status and overall survival between empiric RAI treated and untreated DTC patients.

METHODS

A retrospective study comparing differentiated thyroid cancer patients with negative diagnostic whole-body scan and elevated thyroglobulin levels submitted or not to empiric radioactive iodine therapy in a thyroid cancer referral center. The main outcome measures were ATA Response to Therapy Stratification at 6-12 months after RAI ablative dose, at 6-18 months after negative dxWBS and last follow-up visits.

RESULTS

Overall, 120 DTC patients with stimulated Tg >10 ng/ml and negative dxWBS were included in this study. Overall, 53 patients were submitted to empiric RAI and 67 were in the control group. No difference was observed in ATA Response to Therapy Stratification after RAI ablation or at the end of follow-up between groups. Also, no difference was found in terms of Tg changes response. After more than 10 years of follow-up, 17 patients died (13 from treated and 4 from untreated group).

CONCLUSIONS

Empiric RAI treatment was not associated with better long-term ATA response to therapy status or overall survival.

Exosomal miR-130a-3p promotes the progression of differentiated thyroid cancer by targeting insulin-like growth factor 1

The aim of the present study was to determine the expression and diagnostic value of exosomal miR-130a-3p in the serum of patients with differentiated thyroid cancer (DTC). Exosomes were isolated from the serum of patients with DTC and were identified using transmission electron microscopy. A novel exosomal miRNA, miR-130a-3p, was found to be significantly decreased in the serum of patients with DTC compared with those with benign thyroid tumors and healthy controls. Further study revealed that exosomal miR-130a-3p was correlated with the malignant characteristics of DTC, including tumor diameter, lymph node metastasis (LNM) and higher TNM stage. Receiver operating characteristic curve analysis demonstrated that the area under the curve of exosomal miR-130a-3p was better compared with that of TgAb and Tg in patients with DTC. More importantly, the combined use of exosomal miR-130a-3p, TgAb and Tg significantly enhanced the sensitivity and specificity, indicating that exosomal miR-130a-3p is a sensitive biomarker for DTC. A dual luciferase reporter assay indicated that insulin-like growth factor (IGF)-1 was a target gene of miR-130a-3p. Pearson's correlation analysis revealed a negative correlation between serum IGF-1 and serum exosomal miR-130a-3p levels. More importantly, exosomes from patients with DTC increased the expression of IGF-1 and p-PI3K/p-AKT, but these effects were abolished by siRNA targeting IGF-1 in TPC-1 cells. Taken together, the findings of the present study indicated that reduced exosomal miR-130a-3p levels were associated with the risk of DTC and may be used as a biomarker for the diagnosis of DTC.

Current practice in patients with differentiated thyroid cancer

Considerable changes have occurred in the management of differentiated thyroid cancer (DTC) during the past four decades, based on improved knowledge of the biology of DTC and on advances in therapy, including surgery, the use of radioactive iodine (radioiodine), thyroid hormone treatment and availability of recombinant human TSH. Improved diagnostic tools are available, including determining serum levels of thyroglobulin, neck ultrasonography, imaging (CT, MRI, SPECT-CT and PET-CT), and prognostic classifications have been improved. Patients with low-risk DTC, in whom the risk of thyroid cancer death is <1% and most recurrences can be cured, currently represent the majority of patients. By contrast, patients with high-risk DTC represent 5-10% of all patients. Most thyroid cancer-related deaths occur in this group of patients and recurrences are frequent. Patients with high-risk DTC require more aggressive treatment and follow-up than patients with low-risk DTC. Finally, the strategy for treating patients with intermediate-risk DTC is frequently defined on a case-by-case basis. Prospective trials are needed in well-selected patients with DTC to demonstrate the extent to which treatment and follow-up can be limited without increasing the risk of recurrence and thyroid cancer-related death.

Reappraising the Diagnostic Accuracy of Post-Treatment Whole-Body Scans for Differentiated Thyroid Carcinoma

Initial treatment for differentiated thyroid carcinoma (DTC) often consists of surgery and the administration of radioiodine. In this context, post-treatment Whole-Body Scans (ptWBS) are currently recommended, but data on its diagnostic accuracy are rare. The aim of the study was to evaluate the performance of ptWBS for distant metastasis in DTC patients. We included DTC patients who received radioiodine and underwent ptWBS between 2009-2015. The medical data were independently reviewed by two specialists to evaluate the concordance of positive distant ptWBS uptake and distant metastasis documented by imaging exams (gold standard). We studied 268 DTC patients. The mean age was 46±16 years (82% women), and papillary thyroid carcinoma was diagnosed in 87% of the patients. The median tumor size was 2.7 cm, 40% had lymph node involvement, and 11% had distant metastasis. Twenty-eight patients (10%) had distant ptWBS uptake, and nine of them (32%) were false-positives. In addition, nine false-negative ptWBS uptakes were identified. The overall performance of ptWBS showed 68% sensitivity and 96% specificity with significantly different performance according to the American Thyroid Association (ATA) risk groups. While the ptWBS performance for ATA low-intermediate-risk showed 29% sensitivity, 97% specificity, and Kappa of 0.19, the ATA high-risk group ptWBS displayed high sensitivity (82%), specificity (100%), and good agreement (Kappa 0.74). ptWBS is useful for a subgroup of ATA high-risk DTC patients. The overall poor performance of ptWBS suggests that it should be reconsidered for routine use in ATA at low to intermediate risk: the exam has little value to this subgroup.

The Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Differentiated Thyroid Cancer Patients with Biochemical Recurrence and Negative Whole-Body Radioiodine Scintigraphy and Evaluation of the Possible Role of a Limited Regional Scan

Purpose of the Study

¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) is used in the management of recurrent differentiated thyroid cancer (DTC) patients presented with rising thyroglobulin (Tg) or anti-Tg antibody (Atg) levels and negative whole-body I-131 scan (WBS). We aimed to evaluate the utility of regional or limited PET/CT in a large population preset with variable Tg/(ATg) levels.

Materials and Methods

In a retrospective study, we analyzed 137 PET/CT done on DTC patients presented with raised Tg/Atg and negative WBS. Retrospective evaluation of other available clinical information was done.

Results

One hundred and thirty-seven patients aged 8-72 years (41 ± 17.7 years) were included in the study. Eighty-nine (64.9%) patients had positive findings on ¹⁸F-FDG PET-CT. It included thyroid bed recurrence, cervical, mediastinal lymphadenopathy, lung, and bone lesions. In addition, 36 patients had metabolically inactive lung nodules detected on CT. Serum Tg and female sex were the only predictors for a positive PET scan. In most (97.1%) of the patients, the disease was limited to the neck and thoracic region.

Conclusions

PET/CT is an excellent imaging modality for evaluating DTC patients presented with biochemical recurrence. It not only finds the disease in more than 80% of the patients but also detects distant metastatic disease, which precludes regional therapies. Lesions were noted mostly in the neck and thoracic region with very few distant skeletal metastases (4/137 patients). In most of the patients, routine vertex to mid-thigh imaging could be avoided.

The revised clinical practice guidelines on the management of thyroid tumors by the Japan Associations of Endocrine Surgeons: Core questions and recommendations for treatments of thyroid cancer

The Japan Associations of Endocrine Surgeons has developed the revised version of the Clinical Practice Guidelines for Thyroid Tumors. This article describes the guidelines translated into English for the 35 clinical questions relevant to the therapeutic management of thyroid cancers. The objective of the guidelines is to improve health-related outcomes in patients with thyroid tumors by enabling users to make their practice evidence-based and by minimizing any variations in clinical practice due to gaps in evidential knowledge among physicians. The guidelines give representative flow-charts on the management of papillary, follicular, medullary, and anaplastic thyroid carcinoma, along with recommendations for clinical questions by presenting evidence on the relevant outcomes including benefits, risks, and health conditions from patients' perspective. Therapeutic actions were recommended or not recommended either strongly (◎◎◎ or XXX) based on good evidence (😊)/good expert consensus (+++), or weakly (◎, ◎◎ or X, XX) based on poor evidence (😣)/poor expert consensus (+ or ++). Only 10 of the 51 recommendations given in the guidelines were supported by good evidence, whereas 35 were supported by good expert consensus. While implementing the current guidelines would be of help to achieve the objective, we need further clinical research to make our shared decision making to be more evidence-based.

Radioiodine treatment of differentiated thyroid cancer related to guidelines and scientific literature

In differentiated thyroid cancer (DTC), radioiodine is administered to eliminate residual normal thyroid tissue after thyroidectomy (ablative treatment), to treat residual microscopic disease (adjuvant treatment), and to treat macroscopic or metastatic disease. Currently, treatment of DTC with ¹³¹I is still a matter of controversy due to the absence of prospective clinical trials assessing its benefit in terms of overall survival and recurrence-free interval. The current recommendations of the experts are based on observational retrospective data and on their interpretation of the literature. Pending the results of the prospective trials that are currently underway, the use of ¹³¹I seems to be justified not only in high-risk patients, but also in intermediate-risk and low-risk patients. The guidelines of The American and British Thyroid Association, European and American Societies of Nuclear Medicine, The European Consensus Group and the latest edition of National Comprehensive Cancer Network (NCCN) were considered in drawing up this continuing education document, we also undertook a review of the related scientific literature.

Re-treatment With Adjuvant Radioactive Iodine Does Not Improve Recurrence-Free Survival of Patients With Differentiated Thyroid Cancer

Introduction: Loco regional persistence or recurrence of differentiated thyroid cancer (DTC) is frequent despite initial thyroidectomy and radioactive iodine therapy (RAI). The aim of this study was to analyze the impact of a complementary adjuvant RAI (Ad-RAI) on disease recurrence following re-operation on patients with locally persistent or recurrent DTC. Patients and Methods: A retrospective study of 85 patients with DTC was conducted. All patients were initially treated with total thyroidectomy and RAI, and re-operated for a locally persistent or recurrent disease. Propensity score was calculated to predict the impact of Ad-RAI on survival after reoperation, and to reduce the bias of the limited sample size and the prognostic tests. Results: 49 (58%) patients were re-treated with Ad-RAI after re-operation while 36 (42%) were only followed up. Disease recurrence after re-treatment (re-operation ± Ad-RAI) was detected in 31 patients (36.5%). In multivariate analysis, age >55 years (HR: 3.9 [1.6; 9.5]; p < 0.00001) was the main poor prognostic factor for recurrence-free survival. Three parameters independently influenced the decision to administer ad-RAI: low number of previous RAI administrations, Nx before re-operation, and pTg > 30 μg/l. These parameters were incorporated in the Propensity score calculation. If ad-RAI tended to improve recurrence-free survival (median survival 17.4 vs. 10.9 months), adjustment using the Propensity score removed any difference between the groups (p = 0.54), confirming the limited value of ad-RAI. Conclusion: In patients with locally persistent or recurrent DTC, age is the main independent prognostic factor. Adjuvant RAI does not improve recurrence-free survival of DTC patients.

Outcome of Patients With Differentiated Thyroid Cancer Treated With 131-Iodine on the Basis of a Detectable Serum Thyroglobulin Level After Initial Treatment

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

European Perspective on 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: Proceedings of an Interactive International Symposium

BACKGROUND

The American Thyroid Association (ATA) management guidelines for patients with thyroid nodules and differentiated thyroid cancer (DTC) are highly influential practice recommendations. The latest revision appeared in 2015 ("ATA 2015"). These guidelines were developed predominantly by North American experts. European experts frequently have different perspectives, given epidemiological, technological/methodological, practice organization, and medicolegal differences between the respective regions.

SUMMARY

Divergent viewpoints were the focus of an invited symposium organized by the European Association of Nuclear Medicine involving 17 European thyroidologists, four ATA Guidelines Taskforce members, and an audience of 200 international experts. The group discussed the preoperative assessment of thyroid nodules, surgery and the role of pathology, radioiodine (RAI) therapy (RAIT), the assessment of initial therapy and dynamic risk stratification, and the treatment of persistent disease, recurrences, and advanced thyroid cancer. The dialogue resulted in this position paper contrasting European and ATA 2015 perspectives on key issues. One difference pertains to the permissiveness of ATA 2015 regarding lobectomy for primary tumors ≤4 cm. European panelists cited preclusion of RAIT, potential need for completion thyroidectomy, frequent inability to avoid chronic thyroid hormone replacement, and limitations of supportive evidence as arguments against widely applying lobectomy. Significant divergence involved ATA 2015's guidance regarding RAIT. European panelists favored wider use of postoperative RAIT than does ATA 2015. Rationales included the modality's association with favorable patient outcomes and generally limited toxicity, and lack of high-quality evidence supporting withholding RAIT. Additionally, European panelists favored recombinant human thyrotropin (rhTSH) in more settings than does ATA 2015, citing avoidance of hypothyroid morbidity and quality-of-life impairment, without apparent sacrifice in oncologic outcomes. Based on clinical evidence plus theoretical advantages, European experts advocated dosimetric versus fixed-activity RAIT approaches for advanced DTC. European panelists noted that the ATA 2015 risk-stratification system requires information sometimes unavailable in everyday practice. ATA 2015 recommendations regarding RAI-refractory DTC should consider potential palliative benefits of RAIT in patients who also have RAI-susceptible lesions.

CONCLUSIONS

European panelists suggested modifications to approximately one-third of ATA 2015 recommendations. Varying European and ATA 2015 perspectives can stimulate analysis and discussion of the literature and performance of primary research to resolve discrepant recommendations and potentially improve patient outcomes.

Prognostic Impact of Direct 131I Therapy After Detection of Biochemical Recurrence in Intermediate or High-Risk Differentiated Thyroid Cancer: A Retrospective Cohort Study

Background: Patients treated for intermediate- or high-risk differentiated thyroid carcinoma (DTC) and Thyroglobulin (TG) elevation during follow-up, require a diagnostic whole-body scan (DWBS) and if positive, ¹³¹I treatment. This approach can lead to a delay in treatment and increased costs. The purpose of this study is to compare the oncologic outcomes associated to administration of direct therapy with ¹³¹I at first biochemical recurrence. Methods: Retrospective cohort study of patients with intermediate- or high-risk DTC treated with total thyroidectomy, ¹³¹I ablation and who developed TG elevation during follow-up, between January 2007 and December 2015. Cohort A included patients who underwent a DWBS with 5 mCi of ¹³¹I, and if negative an MRI and/or ¹⁸FDG PET-CT prior to the therapeutic dosage, and cohort B included those who only received a therapeutic dosage of ¹³¹I, without a DWBS or extensive image studies. Main outcomes were second recurrence (SR) and disease-free survival (DFS). The diagnostic accuracy of DWBS was analyzed. Results: Cohorts A and B had 74 and 41 patients, each. By multivariate analysis, age, differentiation grade, TN classification, ablation dose, and performed DWBS (odds ratio 55.1; 95% CI 11.3-269) were associated with SR (p < 0.0001); age, male gender, ablation dose and performed DWBS (hazard ratio 7.79; 95% CI 3.67-16.5) were independent factors associated with DFS (p < 0.0001). DWBS diagnostic accuracy was 36.48%. Conclusion: ¹³¹I treatment in patients with DTC biochemical recurrence and no DWBS or extensive image studies is associated with a significantly lower frequency of SR and an increased DFS. The diagnostic accuracy of DWBS is low, and its clinical efficiency should be defined in prospective phase III studies.

A Review of TENIS Syndrome in Hospital Pulau Pinang

Introduction:

The treatment for differentiated thyroid cancers (DTCs) has always been radioactive iodine 131I therapy after definitive surgical management. Clinicians are faced with therapeutic challenges when dealing with patients having thyroglobulin-elevated negative iodine scintigraphy (TENIS) syndrome (elevated serum thyroglobulin [Tg] levels but negative whole-body scans [WBSs]).

Objective:

The aim of the study was to determine the prevalence of TENIS syndrome in our local setting and to evaluate the use of 18-fluoro-2-deoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) in the management.

Methodology:

The data from DTC patients treated in the Department of Nuclear Medicine, Hospital Pulau Pinang from December 1, 2010, to November 30, 2016, with negative WBS and elevated Tg were reviewed. These patients should have undergone 18F-FDG PET-CT to be included in the study.

Results:

Only forty (10.4%) out of a total of 386 patients treated in Hospital Pulau Pinang during the study fulfilled the inclusion criteria. There were 28 women (70%) with median age of 59 years old. Thirty-four patients (85%) had papillary thyroid cancer (PTC) and six patients had follicular thyroid cancer. The use of 18F-FDG PET-CT revealed 23 patients (57.5%) with 18F-FDG avid metastases suggesting dedifferentiation of thyroid cancers. Based on this study, the probability of detecting FDG-avid disease is higher (P = 0.03) if 18F-FDG PET-CT was performed when Tg ≥15 ng/mL.

Conclusion:

TENIS syndrome constitutes a significant number of cases in our setting. Our data suggest a cutoff Tg ≥15 ng/mL for performing 18F-FDG PET-CT for these patients would be more beneficial than the currently American Thyroid Association recommended cutoff of 10 ng/mL.

Papillary Thyroid Carcinoma Recurrence: Low Yield of Neck Ultrasound With an Undetectable Serum Thyroglobulin Level

OBJECTIVES

To assess the yield of neck ultrasound (US) when serum thyroglobulin (Tg) is undetectable (<0.1 ng/mL) compared to elevated serum Tg in patients with differentiated papillary thyroid carcinoma (PTC) treated with thyroidectomy and radioactive iodine 131 (RAI) ablation.

METHODS

A retrospective chart review was conducted from 2010 through 2015 at an academic institution evaluating US results in patients with serum Tg levels obtained within 6 months of a neck US examination after thyroidectomy and RAI. The reference standard for recurrence was pathologic results from US-guided fine-needle aspiration (FNA) or follow-up for at least 1 year.

RESULTS

Among 76 patients with undetectable serum Tg levels, there were 19 examinations in 18 patients in which US raised the possibility of recurrence. None of these 18 patients had recurrence by FNA (n = 8) or clinical follow-up of at least 1 year (n = 10). Among 65 patients with elevated serum Tg levels, there were 24 examinations in 22 patients in which US raised the possibility of recurrence. Twelve patients underwent FNA, with 9 patients (34.6%) showing PTC; 7 patients had follow-up neck US examinations showing stability of findings; and 3 patients were lost to follow up. The yield of neck US was significantly lower when serum Tg was undetectable compared to when levels were elevated (P = .001).

CONCLUSIONS

Neck US did not identify recurrent PTC when the serum Tg level was undetectable in patients who underwent total thyroidectomy and RAI therapy. Eliminating neck US when serum TG levels are undetectable could decrease unnecessary imaging examinations without negatively affecting the ability to detect recurrent disease.

Radioiodine Refractory Differentiated Thyroid Cancer: Time to Update the Classifications

BACKGROUND

The management of aggressive and progressing metastatic differentiated thyroid cancer (DTC) is very difficult, and the determination as to when such patients are refractory to ¹³¹I therapy (e.g., radioiodine refractory) is problematic and controversial.

OBJECTIVE

The objective of this review is to discuss (i) the present major classifications of radioiodine refractory disease in DTC, (ii) factors that should be considered before designating a patient's DTC as radioiodine refractory, (iii) potential approaches and caveats to help manage and minimize a patient's exclusion from an ¹³¹I therapy that may have potential benefit in patients with aggressive and progressing metastatic DTC, (iv) next steps for revision of the classifications of radioiodine refractory DTC, and (v) areas for future research.

SUMMARY

To date, the classifications of radioiodine refractory DTC, although very useful, are not sacrosanct especially in the context of individualized patient management, and merely because a patient meets one or more of the various classifications, one should not consider by definition, fiat, or de facto that that a patient's DTC is radioiodine refractory. Rather, each patient should be individually managed with a good understanding of the limitations of the various classifications and potential approaches to help manage that patient. With awareness of the suggestions and caveats discussed herein and with assessment of the many other factors that affect the patient's specific clinical situation, the managing physician can deliver appropriate individualized patient care. A multi-organizational committee should be established as a standing committee to supervise and assist in the update of the classifications of radioiodine refractory DTC, including discussions of their limitations.

CONCLUSION

Classifications to help determine radioiodine refractory disease will continue to evolve as (i) more studies are published, (ii) managing physicians better understand the limitations and confounding factors of present classifications, and (iii) new agents either increase or reestablish ¹³¹I uptake.

Follow-up of differentiated thyroid cancer - what should (and what should not) be done

The treatment paradigm for thyroid cancer has shifted from a one-size-fits-all approach to more personalized protocols that range from active surveillance to total thyroidectomy followed by radioiodine remnant ablation. Accurate surveillance tools are available, but follow-up protocols vary widely between centres and clinicians, owing to the lack of clear, straightforward recommendations on the instruments and assessment schedule that health-care professionals should adopt. For most patients (that is, those who have had an excellent response to the initial treatment and have a low or intermediate risk of tumour recurrence), an infrequent assessment schedule is sufficient (such as a yearly determination of serum levels of TSH and thyroglobulin). Select patients will benefit from second-line imaging and more frequent assessments. This Review discusses the strengths and weaknesses of the surveillance tools and follow-up strategies that clinicians use as a function of the initial treatment and each patient's risk of recurrence.

Outcome after ablation in patients with low-risk thyroid cancer (ESTIMABL1): 5-year follow-up results of a randomised, phase 3, equivalence trial

BACKGROUND

In ESTIMABL1, a randomised phase 3 trial of radioactive iodine (131I) administration after complete surgical resection in patients with low-risk thyroid cancer, 92% of patients had complete thyroid ablation at 6-10 months, defined as a recombinant human thyroid-stimulating hormone (rhTSH)-stimulated serum thyroglobulin concentration of 1 ng/mL or less and normal findings on neck ultrasonography. Equivalence was shown between low-activity (1·1 GBq) and high-activity (3·7 GBq) radioactive iodine and also between the use of rhTSH injections and thyroid hormone withdrawal. Here, we report outcomes after 5 years of follow-up.

METHODS

This multicentre, randomised, open-label, equivalence trial was done at 24 centres in France. Between March 28, 2007, and Feb 25, 2010, we randomly assigned (1:1:1:1) adults with low-risk differentiated thyroid carcinoma who had undergone total thyroidectomy to one of four strategies, each combining one of two methods of thyrotropin stimulation (rhTSH or thyroid hormone withdrawal) and one of two radioactive iodine activities (1·1 GBq or 3·7 GBq). Randomisation was by computer-generated sequence, with variable block size. Follow-up consisted of a yearly serum thyroglobulin measurement on levothyroxine treatment. Measurement of rhTSH-stimulated thyroglobulin and neck ultrasonography were done at the discretion of the treating physician. No evidence of disease was defined as serum thyroglobulin of 1 ng/mL or less on levothyroxine treatment and normal results on neck ultrasonography, when performed. This study was registered with ClinicalTrials.gov, number NCT00435851.

FINDINGS

726 patients (97% of the 752 patients originally randomised) were followed up. At a median follow-up since randomisation of 5·4 years (range 0·5-9·2), 715 (98%) had no evidence of disease. The other 11 had either structural disease (n=4), raised serum thyroglobulin concentration (n=5), or indeterminate findings on neck ultrasonography (n=2). At ablation, six of these patients had received 1·1 GBq radioactive iodine (five after rhTSH and one after withdrawal) and five had received 3·7 GBq (two after rhTSH and three after withdrawal). TSH-stimulated (either after rhTSH injections or thyroid hormone withdrawal according to the treatment group) thyroglobulin concentration measured at the time of ablation was prognostic for structural disease status at ablation, ablation status at 6-10 months, and the final outcome.

INTERPRETATION

Our findings suggest that disease recurrence was not related to the strategy used for ablation. These data validate the use of 1·1 GBq radioactive iodine after rhTSH for postoperative ablation in patients with low-risk thyroid cancer.

FUNDING

French National Cancer Institute (INCa), French Ministry of Health, and Sanofi Genzyme.

Radioiodine refractory differentiated thyroid cancer

Differentiated thyroid cancer (DTC) is usually curable with surgery, radioactive iodine (RAI), and thyroid-stimulating hormone (TSH) suppression. However, local recurrence and/or distant metastases occur in approximately 15% of cases during follow-up, and nearly two-thirds of these patients will become RAI-refractory (RR-DTC) with a poor prognosis. This review focuses on the most challenging and rapidly evolving aspects of RR-DTC, and we discuss the considerable improvement in more accurately defining RR-DTC, more effective therapeutic strategies, and describe the diagnosis, pathogenesis, and future prospects of RR-DTC. Along with the detection of serum thyroglobulin and anatomic imaging modalities, such as ultrasound and computer tomography, radionuclide molecular imaging plays a vital role in the evaluation of RR-DTC. In addition, continual progress has been made in the management of RR-DTC, including watchful waiting under appropriate TSH suppression, local treatment approaches, and systemic therapies (molecular targeted therapy, redifferentiation therapy, gene therapy, and cancer immunotherapy). These all hold promise to change the natural history of RR-DTC.

Clinical Value of 99mTc-3PRGD2 SPECT/CT in Differentiated Thyroid Carcinoma with Negative 131I Whole-Body Scan and Elevated Thyroglobulin Level

The aim of this study was to assess the usefulness of integrin imaging with ^99mTc-PEG₄-E[PEG₄-c(RGDfK)]₂ (^99mTc-3PRGD2) single photon emission computed tomography (SPECT)/computed tomography (CT) in detecting recurrent disease in patients with differentiated thyroid cancer (DTC), negative radioiodine whole-body scan (WBS) and high serum thyroglobulin (Tg). Thirty-seven patients who underwent total thyroidectomy followed by radioactive iodine ablation and had negative radioiodine WBS but elevated Tg levels were included. ^99mTc-3PRGD2 SPECT/CT was performed 1 week after the negative diagnostic ¹³¹I WBS. Diagnostic performance indicators, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), for ^99mTc-3PRGD2 SPECT/CT was calculated. The correlations between SPECT/CT results and clinic-pathological characteristics were examined. In 30 (81.1%) of the 37 patients, ^99mTc-3PRGD2 SPECT/CT showed positive uptake. The sensitivity, specificity, PPV, and NPV of SPECT/CT to detect recurrent disease at follow-up were 96.6%, 75%, 93.3% and 85.7%, respectively. The sensitivity and PPV of SPECT/CT increased with increasing serum Tg levels. ^99mTc-3PRGD2 SPECT/CT showed high sensitivity and PPV in the detection of recurrence among DTC patients with higher Tg levels and negative WBS, and the probability of obtaining a positive SPECT/CT result was related with the level of Tg.

Biochemical Testing in Thyroid Disorders

This article summarizes the main principles for the appropriate use of laboratory testing in the diagnosis and management of thyroid disorders, as well as controversies that have arisen in association with some of these biochemical tests. To place a test in perspective, its sensitivity and accuracy should be taken into account. Ordering the correct laboratory tests facilitates the early diagnosis of a thyroid disorder and allows for timely and appropriate treatment. This article focuses on a comprehensive update regarding thyroid-stimulating hormone, thyroxine/triiodothyronine, thyroid autoantibodies, thyroglobulin, and calcitonin. Clinical uses of these biochemical tests are outlined.

Higher preablative serum thyroid-stimulating hormone level predicts radioiodine ablation effectiveness in patients with differentiated thyroid carcinoma

INTRODUCTION

Radioiodine ablation of remnant thyroid tissue is an important adjuvant therapy of differentiated thyroid carcinoma (DTC) after thyroidectomy. Elevated serum thyroid-stimulating hormone (TSH) level is necessary for successful ablation. The optimum level of serum TSH level necessary for successful radioiodine ablation of well-DTC is, however, yet to be defined. We aimed to determine whether higher serum TSH level will result in a better rate of complete ablation of well-DTC using iodine-131 (I) following initial thyroidectomy.

PATIENTS AND METHODS

A total of 109 patients with differentiated thyroid cancer were divided into four treatment groups on the basis of serum TSH levels. They were followed up from 6 to 12 months after treatment with stimulated serum thyroglobulin level and a diagnostic whole-body scan with radioactive iodine I to determine early response.

RESULTS

Sixty-four patients had papillary thyroid carcinoma, whereas 45 patients had follicular carcinoma. An excellent response was observed in 66.7% of patients with TSH level more than 90 μIU/ml, 72.2% in the group with TSH level of 60-89 μIU/ml, 48.5% when TSH was 30-59 μIU/ml and 26.7% when TSH was less than 30 μIU/ml (P=0.002).

CONCLUSION

Higher preablative serum TSH predicts a better rate of ablation in patients with differentiated thyroid cancer treated with I after thyroidectomy.

Survival Analysis of Papillary Thyroid Carcinoma in Relation to Stage and Recurrence Risk: A 20-Year Experience in Pakistan

OBJECTIVE

The aim of this study was to evaluate the overall and progression-free survival of papillary thyroid carcinoma (PTC), comparing the American Thyroid Association (ATA) guideline for risk of recurrence with the TNM staging system with dynamic assessment at 2 years.

PATIENTS AND METHODS

This study is a retrospective analysis of 689 PTC patients over a 20-year period at a single center. Disease-free survival based on the TNM staging and ATA recurrence risk was calculated using Kaplan-Meier curves. Dynamic response assessment during the first 2 years was compared for both systems. Survival was calculated based on age, baseline resectability, and postthyroidectomy serum tumor marker levels.

RESULTS

Six hundred eighty-nine (72.2%) of the total thyroid cancer patients had PTC. Four hundred sixty-nine patients were females, and 220 patients were males. The age range was 6 to 87 years. Five hundred thirty-five patients were resectable, and 56 patients were unresectable. One hundred fifty-one patients were excluded due to insufficient information on recurrence risk. By ATA categorization, 39% had low risk, no disease-related mortality; 44% had intermediate risk, 3 died; and 17% had high risk, 32 died. The 5-year disease-free survival was 54%, 26%, and 5% in low-, intermediate-, and high-risk groups, respectively. The log-rank test showed a significant difference in the percent survival (P < 0.01). TNM stage wise, in terms of survival, 1.3% in stage I, 2.2% in stage II, 0% in stage III, and 37.5% in stage IV died. The 20-year disease-free survival showed the following: stage I, 43%; stage II, 28%; stage III, 18%; and stage IV, 2%. There is significant difference in survival rate (P < 0.01). Both ATA risk classification and TNM staging were significant predictors of disease-free survival. On bivariate analysis, ATA classification (hazards ratio, 2.1; 95% confidence interval, 1.64-2.67; P = 0.001) was better predictive of overall survival versus TNM classification (hazards ratio, 1.3; 95% confidence interval, 1.11-1.43; P = 0.063).

CONCLUSIONS

The ATA risk stratification and continuous reassessment during the first 2 years predicts disease-free survival better than the TNM staging. Age older than 45 years, unresectable disease, and elevated postthyroidectomy thyroglobulin levels dictate a poorer prognosis.

Targeted treatments of radio-iodine refractory differentiated thyroid cancer

Radio-iodine refractory metastatic thyroid cancers are rare and their management was until recently relatively complex. New therapeutic agents, kinase inhibitors, joined since the early 2000s the fight against these cancers with very promising results. These targeted agents showed for two of them (sorafenib; lenvatinib), in randomized phase III trials, a significant improvement in response rate and progressionfree survival when compared to placebo, leading to the first approval for radio-iodine refractory metastatic thyroid cancers. In parallel, patients also benefited from the development of interventional radiology techniques and organization of cares in oncology, with multidisciplinary management strengthened by the creation of a national network (TUTHYREF).

Therapeutic options in papillary thyroid carcinoma: current guidelines and future perspectives

The treatment of papillary thyroid cancer is now based on individual patient risk and response to therapies. Molecular techniques are increasingly being used to risk stratify and to guide therapeutic decisions. There have been advances in the treatment of local disease through surgery or radioiodine. Directed techniques can target metastatic disease including bisphosphonates, radiofrequency ablation or radiotherapy. Systemic therapies such as tyrosine kinase inhibitors show great promise although such treatment must be individualized. Future therapies will target treating radioiodine refractory disease.

Challenges of thyroid cancer management in amiodarone-treated patients: a case report

Thyroid carcinoma (TC) is the most common endocrine malignancy. Although the overall prognosis for patients with TC is good, up to 20–30% of patients have recurrent or persistent disease after conventional therapy by surgical resection and radioactive iodine (RAI). Amiodarone is a highly efficient anti-arrhythmic drug with a very long half-life, so it may interfere with RAI many months after the drug withdrawal. This case report mirrors the challenges of thyroid cancer management in an amiodarone-treated patient.

Detection of metastases from differentiated thyroid cancer by different imaging techniques (neck ultrasound, computed tomography and [18F]-FDG positron emission tomography) in patients with negative post-therapeutic ¹³¹I whole-body scan and detectable serum thyroglobulin levels

INTRODUCTION

DTC patients having detectable Tg and negative post-therapeutic (131)I-WBS have to be investigated by different imaging techniques to detect metastases.

PURPOSE

Comparison of neck US, CT and [18F]-FDG PET scan.

METHODS

In 49 DTC patients with biochemical disease, neck was examined by US, CT and [18F]-FDG PET. FNA was performed and Tg was determined by FNA-Tg in selected cases of suspicious lymph nodes. Thorax was examined by CT and PET. Serum Tg was measured on LT4 therapy (basal Tg) and after the stimulation with recombinant human TSH (peak Tg).

RESULTS

A thyroid remnant was seen by US, CT and PET in eight patients; recurrences were seen by US, CT and PET in six, five and five patients, respectively. Two metastatic nodes were identified by US and CT but not by PET. Lung micronodules were detected by CT in 7/49 (14.3 %) patients and by FDG PET in three of them. Basal Tg ranged from 0.5-1,725 ng/ml while peak Tg ranged from 0.5 to 2,135 ng/ml: the distribution between positive and negative patients was similar. Bone scan was negative in all cases.

CONCLUSIONS

In DTC patients with detectable Tg and negative I-131 post-therapy WBS, imaging examination revealed remnant or metastases in 43 % of cases. Remnant and recurrences were equally detected by the three techniques; US was better than [18F]-FDG PET for lymph node metastases since this latter method can give false both positive and negative results; chest examination is best made by CT versus FDG PET due to its higher spatial resolution.

Practice trends in patients with persistent detectable thyroglobulin and negative diagnostic radioiodine whole body scans: a survey of American Thyroid Association members

BACKGROUND

Management of patients with thyroglobulin (Tg)-positive/scan-negative thyroid cancer remains challenging. American Thyroid Association (ATA) guidelines recommend potential use of empiric (131)I therapy and various scanning modalities, but no standard for managing such cases exists.

METHODS

We surveyed ATA members to assess current practice in management of patients with Tg-positive/scan-negative disease. Members participated in a web-based survey of six case scenarios of Tg elevations but iodine scan negativity.

RESULTS

A total of 288 ATA members (80% male) participated. Patient age, sex, and basal and stimulated Tg varied between the cases. Respondents were asked their opinion regarding empiric (131)I therapy use, including (131)I dose, use and duration of low-iodine diet, thyroxine withdrawal or recombinant human thyrotropin (rhTSH), and utilization of additional imaging (neck ultrasound (US) or positron emission tomography/computed tomography (PET/CT)) and reconsideration of (131)I therapy. Between 16% and 51% recommended initial use of empiric (131)I for the various scenarios. The majority chose a (131)I dose between 75 and 150 mCi, and 73% employed a low-iodine diet for two or more weeks. Preference between thyroxine withdrawal versus rhTSH was evenly split. More than 98% obtained a neck US if empiric (131)I was not given; 52-89% would proceed to PET/CT if US was negative. Only 44% used rhTSH stimulation in PET scan preparation. (131)I use was more common with stimulated Tg significantly >10 ng/mL. (131)I therapy was slightly more likely with PET-positive (56%) than PET-negative status (45%). Respondents were split regarding empiric (131)I if basal and stimulated Tg increased ≥150% over two years. Providers in North America less commonly utilized (131)I treatment than those from other areas. In the face of possible heterophilic antibody interference in the Tg assay, the majority did not recommend (131)I therapy.

CONCLUSIONS

Empiric (131)I therapy is still utilized for patients with Tg-positive/scan-negative disease. Neck US is frequently used to further evaluate such cases as (18)FDG-PET/CT, albeit the latter is used somewhat less often. Use of (131)I therapy correlated with the degree of Tg elevation or development of Tg antibodies, and was recommended more commonly with PET-positive than PET-negative status in patients with lower Tg levels. (131)I was less commonly used by providers within North America.

Do negative 124I pretherapy positron emission tomography scans in patients with elevated serum thyroglobulin levels predict negative 131I posttherapy scans?

BACKGROUND

The management of patients with differentiated thyroid cancer (DTC) who have elevated serum thyroglobulin (Tg) levels and negative (131)I or (123)I scans is problematic, and the decision regarding whether or not to administer (131)I therapy (a "blind" therapy) is also problematic. While (124)I positron emission tomography (PET) imaging has been shown to detect more foci of residual thyroid tissue and/or metastases secondary to DTC than planar (131)I images, the utility of a negative (124)I PET scan in deciding whether or not to consider performing blind (131)I therapy is unknown. The objective of this study was to determine whether a negative (124)I pretherapy PET scan in patients with elevated serum Tg levels and negative (131)I or (123)I scans predicts a negative (131)I posttherapy scan.

METHODS

Several prospective studies have been performed to compare the radiopharmacokinetics of (124)I PET versus (131)I planar imaging in patients who 1) had histologically proven DTC, 2) were suspected to have metastatic DTC (e.g., elevated Tg, positive recent fine-needle aspiration cytology, suspicious enlarging mass), and 3) had (131)I planar and (124)I PET imaging performed. Using these criteria, we retrospectively identified patients who had an elevated Tg, a negative diagnostic (131)I/(123)I scan, a negative diagnostic (124)I PET scan, therapy with (131)I, a post-therapy (131)I scan, and a prior (131)I therapy with a subsequent positive post-(131)I therapy scan. For each scan, two readers categorized every focus of (131)I and (124)I uptake as positive for thyroid tissue/metastases or physiological.

RESULTS

Twelve patients met the above criteria. Ten of these 12 patients (83%) had positive foci on (131)I posttherapy scan.

CONCLUSION

In our selected patient population, (131)I posttherapy scans are frequently positive in patients with elevated serum Tg levels, a negative diagnostic (131)I or (123)I scan, and a negative (124)I PET scan. Thus, for a patient with elevated serum Tg level, negative diagnostic (131)I planar scan, and a prior post-(131)I therapy scan that was positive, a negative (124)I PET scan will have a low predictive value for a negative post-(131)I therapy scan and should not be used to exclude the option of blind (131)I therapy.

Recurrent differentiated thyroid cancer: towards personalized treatment based on evaluation of tumor characteristics with PET (THYROPET Study): study protocol of a multicenter observational cohort study

BACKGROUND

After initial treatment of differentiated thyroid carcinoma (DTC) patients are followed with thyroglobulin (Tg) measurements to detect recurrences. In case of elevated levels of Tg and negative neck ultrasonography, patients are treated 'blindly' with Iodine-131 (131I). However, in up to 50% of patients, the post-therapy scan reveals no 131I-targeting of tumor lesions. Such patients derive no benefit from the blind therapy but are exposed to its toxicity. Alternatively, iodine-124 (124I) Positron Emission Tomography/Computed Tomography (PET/CT) has become available to visualize DTC lesions and without toxicity. In addition to this, 18F-fluorodeoxyglucose (18F-FDG) PET/CT detects the recurrent DTC phenotype, which lost the capacity to accumulate iodine. Taken together, the combination of 124I and 18F-FDG PET/CT has potential to stratify patients for treatment with 131I.

METHODS/DESIGN

In a multicenter prospective observational cohort study the hypothesis that the combination of 124I and 18F-FDG PET/CT can avoid futile 131I treatments in patients planned for 'blind' therapy with 131I, is tested.One hundred patients planned for 131I undergo both 124I and 18F-FDG PET/CT after rhTSH stimulation. Independent of the outcome of the scans, all patients will subsequently receive, after thyroid hormone withdrawal, the 131I therapy. The post 131I therapeutic scintigraphy is compared with the outcome of the 124I and 18F-FDG PET/CT in order to evaluate the diagnostic value of the combined PET modalities.This study primary aims to reduce the number of futile 131I therapies. Secondary aims are the nationwide introduction of 124I PET/CT by a quality assurance and quality control (QA/QC) program, to correlate imaging outcome with histopathological features, to compare 124I PET/CT after rhTSH and after withdrawal of thyroid hormone, and to compare 124I and 131I dosimetry.

DISCUSSION

This study aims to evaluate the potential value of the combination of 124I and 18F-FDG PET/CT in the prevention of futile 131I therapies in patients with biochemically suspected recurrence of DTC. To our best knowledge no studies addressed this in a prospective cohort of patients. This is of great clinical importance as a futile 131I is a costly treatment associated with morbidity and therefore should be restricted to those likely to benefit from this treatment.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01641679.

How to manage patients with differentiated thyroid cancer and a rising serum thyroglobulin level

Serum thyroglobulin (sTg) is the marker for monitoring persistence/recurrence of differentiated thyroid cancer, in patients without sTg antibodies. Patients with undetectable basal sTg or peak sTg <2 ng/mL are cured with low risk to recur. Newly detectable level of sTg indicates the recurrence. The significance of increasing sTg in patients treated with emithyroidectomy or total-thyroidectomy but not ablated with radioiodine is undefined. A doubling time <1 year may be a poor prognostic factor, but this is more relevant in cases with high levels of sTg. Because of its sensitivity, neck ultrasound should be performed at any visit, especially when an increased sTg is seen.

Lung uptake on I-131 therapy and short-term outcome in patients with lung metastasis from differentiated thyroid cancer

Objective

It is sometimes difficult to assess I-131 lung uptake at the initial I-131 therapy because of strong artifacts from I-131 uptake in the thyroid bed. The aim of this study was to analyze the lung uptake at the second I-131 therapy for lung metastasis in patients who did not have lung uptake at the initial therapy from differentiated thyroid carcinoma (DTC). Then, we also analyzed the relationship between the initial lung uptake and short-term outcome after I-131 therapies.

Methods

This study included 62 DTC patients with lung metastasis. The patients were classified into 2 groups according to the lung uptake at the initial I-131 therapy such as patients with lung uptake (positive uptake group n = 31) and those without lung uptake (negative uptake group n = 31). The lung uptake was analyzed at the second therapy in both groups. The short-term outcome was also analyzed based on the CT findings of lung metastasis size and serum thyroglobulin level between the two groups.

Results

The positive uptake group showed positive lung uptake at the second therapy in 23 patients (74 %), whereas none of negative uptake group showed any lung uptake at the second therapy (P < 0.01). The positive uptake group significantly decreased in the size of lung metastasis from the initial therapy to the second therapy (20.0 ± 11.7 to 16.6 ± 9.6 mm, P < 0.01) with further decrease after the second therapy (P < 0.05). The serum thyroglobulin level was also significantly decreased from the initial therapy to the second therapy (4348 ± 7011 to 2931 ± 4484 ng/ml, P < 0.05). In contrast, the negative uptake group significantly increased in the size of lung metastasis from the initial therapy to the second therapy (17.3 ± 12.2 to 19.9 ± 14.3 mm, P < 0.01) with further increase after the second therapy (P < 0.01).

Conclusion

No patients without lung uptake at the initial I-131 therapy showed lung uptake at the second therapy, or showed treatment effect. Therefore, second I-131 therapy for these patients with initially negative lung uptake should be considered cautiously.

Therapeutic impact of (18)F-FDG PET/CT in recurrent differentiated thyroid carcinoma

PURPOSE

(18)F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) has proved effective in detecting recurrent or metastatic differentiated thyroid carcinoma (DTC) in the follow-up of operated DTC patients with high thyroglobulin (Tg) levels and negative findings on radioiodine whole-body scan. The aim of this retrospective study was to assess the impact of PET/CT on the planning of appropriate treatment for known recurrent disease in operated DTC patients.

MATERIALS AND METHODS

The study concerned 44 consecutive DTC patients (36 papillary, 8 follicular), who underwent total thyroidectomy and thyroid remnant ablation with (131)I and PET/CT. All patients had proven or strongly suspected recurrent disease judging from neck ultrasound (US) and fine-needle aspiration cytology, and detectable basal Tg levels.

RESULTS

PET/CT findings were positive in 25/44 patients (56.81 %) and negative in 19. A positive PET/CT result predicted resectable tumour recurrences in 19/25 patients, but also detected additional tumour sites that prompted changes to the treatment plan in 6/25 patients (24 %). A negative PET/CT result led to clinical monitoring for 11/19 patients (57.89 %).

CONCLUSIONS

PET/CT can help select patients, who might benefit from a tailored therapy by improving the detection of local recurrences not apparent on neck US or metastases.

Long-term consequence of elevated thyroglobulin in differentiated thyroid cancer

BACKGROUND

Serum thyroglobulin (Tg) is the most sensitive biomarker for recurrence of differentiated thyroid cancer (DTC). We have assessed the changing pattern of stimulated Tg (sTg) and the clinical course of patients with no structural evidence of disease (NSED), based on imaging studies such as neck ultrasonography (US), fluorodeoxyglucose positron emission tomography, and/or chest computed tomogram (CT). We sought to determine if, in patients with DTC who had been treated with bilateral thyroidectomy and remnant ablation with radioactive iodine, sTg 1 year (sTg1) after initial treatment and repeated sTg measurements, 1-2 years after sTg1, helped predict the long-term outcome with respect to structural recurrence and biochemical remission (BR), which is defined as sTg <1 ng/mL.

METHODS

We retrospectively assessed the records of patients with DTC who had been treated with bilateral thyroidectomy and remnant ablation with radioactive iodine between 1995 and 2004. The study included 186 patients who had NSED with sTg1 ≥2 ng/mL and subsequent sTg measurements (sTg2) without additional treatment. Patients were classified into three groups based on their sTg1 measurements: Group A, 2-4.9 ng/mL; Group B, 5-19.9 ng/mL; and Group C, ≥20 ng/mL. Patients were also classified into two groups based on whether sTg2, 1-2 years after sTg1, had decreased by ≥50% (Group 1) or had either decreased by <50% or increased (Group 2). sTg was measured every 1-2 years until structural recurrence or BR.

RESULTS

Patients remaining in NSED showed a decrease in serial sTg. Of patients in Groups A, B, and C, 41%, 17%, and 1%, respectively, achieved BR, and there was a significant difference in the BR rate between Groups 1 and 2 (p<0.001). In patients with structural recurrence, serial sTg generally did not decrease from sTg1. There was a significant difference in the recurrence rate among Groups A, B, and C (p=0.005) and between Groups 1 and 2 (p<0.001).

CONCLUSIONS

We found that 41% of patients with sTg1 in the range 2-5 ng/mL achieved BR, and that sTg1 and percent change of subsequent sTg were predictive of BR. Repeated sTg measurements are useful for predicting patient prognosis in patients with DTC.

New molecular targeted therapy and redifferentiation therapy for radioiodine-refractory advanced papillary thyroid carcinoma: literature review

Although the majority of papillary thyroid carcinoma could be successfully managed by complete surgical resection alone or resection followed by radioiodine ablation, a small proportion of patients may develop radioiodine-refractory progressive disease which is not amenable to surgery, local ablative treatment or other treatment modalities. The use of FDG-PET/CT scan for persistent/recurrent disease has improved the accuracy of restaging as well as cancer prognostication. Given that patients with RAI-refractory disease tend to do significantly worse than those with radioiodine-avid or non-progressive disease, an increasing number of phase I and II studies have been conducted to evaluate the efficacy of new molecular targeted drugs such as the tyrosine kinase inhibitors and redifferentiation drugs. The overall response rate of these drugs ranged between 0–53%, depending on whether the patients had been previously treated with these drugs, performance status and extent of disease. However, drug toxicity remains a major concern in administration of target therapies. Nevertheless, there are also ongoing phase III studies evaluating the efficacy of these new drugs. The aim of the review was to summarize and discuss the results of these targeted drugs and redifferentiation agents for patients with progressive, radioiodine-refractory papillary thyroid carcinoma.

Increasing the yield of recombinant thyroid-stimulating hormone-stimulated 2-(18-fluoride)-flu-2-deoxy-D-glucose positron emission tomography-CT in patients with differentiated thyroid carcinoma

OBJECTIVE

The aim of this study was to assess the accuracy of recombinant thyroid-stimulating hormone (rTSH)-stimulated 2-(18-fluoride)-flu-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography (PET)-CT in detecting recurrence in patients with differentiated thyroid cancer.

METHODS

Consecutive (18)F-FDG PET-CT scans performed with rTSH stimulation between 2007 and 2010 in patients with a history of papillary or follicular thyroid carcinoma were reviewed. PET-CT findings were correlated with thyroglobulin levels, and histological, clinical and radiological follow-up.

RESULTS

58 rTSH PET-CT scans were performed in 47 patients with a previous thyroidectomy and radioiodine ablation. The only indication for PET-CT was a raised thyroglobulin level in 46 of 58 scans, with the remainder for characterisation of equivocal radiology or staging. 25 (43%) of PET-CT scans were positive for recurrent disease. Histological correlation was available for 21 (36%) scans. The overall sensitivity, specificity, positive predictive value and negative predictive value were 69%, 76%, 72% and 73%, respectively. Median unstimulated thyroglobulin in true-positive scans was 33 µg l(-1) and 2.2 µg l(-1) in the remainder (p=0.12). 4 of 35 (11%) patients with unstimulated thyroglobulin levels <10 µg l(-1) had true-positive scans. Median stimulated thyroglobulin in true-positive scans was 320 µg l(-1), and 10 µg l(-1) in the remainder (p=0.046), with no positive scans with a stimulated thyroglobulin <8 µg l(-1). PET-CT directly influenced patient management in 17/58 (29%) scans.

CONCLUSION

rTSH PET-CT is a useful imaging technique for detecting disease recurrence in patients with iodine-resistant differentiated thyroid cancer. Low stimulated thyroglobulin levels are potentially useful in identifying patients unlikely to benefit from a PET-CT scan.

To treat or not to treat: the role of adjuvant radioiodine therapy in thyroid cancer patients

Radioactive iodine (RAI) is used in treatment of patients with differentiated papillary and follicular thyroid cancer. It is typically used after thyroidectomy, both as a means of imaging to detect residual thyroid tissue or metastatic disease, as well as a means of treatment by ablation if such tissue is found. In this paper, we discuss the indications for and the mechanisms of RAI in the treatment of patients with thyroid cancer. We discuss the attendant risks and benefits that come with its use, as well as techniques used to optimize its effectiveness as an imaging tool and a therapeutic modality.

Advances in the follow-up of differentiated or medullary thyroid cancer

The long-term survival of patients with thyroid cancer and the possibility of tumour recurrence up to 30-40 years after the achievement of a disease-free status illustrate the importance of lifelong follow-up in these individuals. This Review discusses the most innovative aspects of follow-up protocols for patients with differentiated thyroid cancer, that is, of papillary or follicular hystotype, and those with medullary thyroid cancer. Particular focus is placed on the relevance of new ultrasensitive assays for thyroglobulin measurement and the option of using recombinant human TSH to stimulate thyroglobulin secretion. Methods to compensate for the loss of diagnostic significance of serum thyroglobulin levels in patients with differentiated thyroid cancer and circulating anti-thyroglobulin antibodies are highlighted, as well as the role of the postoperative calcitonin stimulation test and the clinical relevance of determining the doubling time of calcitonin and carcinoembryonic antigen in patients with medullary thyroid cancer. Moreover, this Review gives some insights into the role of molecular thyroid cancer testing, both for prognostic and for therapeutic purposes. Finally, a general overview of traditional imaging procedures, such as neck ultrasonography, CT, MRI and bone scintigraphy, is provided alongside a comparison with new nuclear imaging tests such as PET.

Thyroid lobe ablation with radioactive iodine as an alternative to completion thyroidectomy after hemithyroidectomy in patients with follicular thyroid carcinoma: long-term follow-up

BACKGROUND

Radioactive iodine lobe ablation (RAI-L-ABL) is a possible alternative to completion thyroidectomy (C-Tx) for follicular thyroid carcinoma (FTC), but no long-term outcome data are available after lobe ablation. We analyzed the long-term outcome of lobe ablation in a series of patients with FTC.

METHODS

This was a retrospective study of patients who were treated with lobe ablation between 1983 and 2008. Of 134 patients with FTC, 37 (27.6%) had lobe ablation with (131)I (30-32 mCi) (RAI-L-ABL), 68 (50.7%) had C-Tx, and 29 (21.6%) had initial total thyroidectomy (T-Tx). The main outcomes analyzed were (131)I uptake after lobe ablation, C-Tx or T-Tx, serum thyroglobulin (Tg), serum thyroid-stimulating hormone (TSH), long-term disease-specific mortality, and disease-free survival.

RESULTS

After lobe ablation, radioiodine uptake was significantly lower for the RAI-L-ABL group (0.6%) than for the C-Tx group (2.0%, p<0.005) or T-Tx group (1.3%, p=0.054). Subsequent remnant ablation was performed in 12 of 37 (32%) patients in the RAI-L-ABL group, in 58 of 68 (85.3%) patients in the C-Tx group, and in 25 of 29 (86.2%) patients in the T-Tx group (p<0.01). With median follow-up of 95 months for the RAI-L-ABL group, 47 months for the C-Tx group, and 53 months for the T-Tx group, there was one death in the RAI-L-ABL group and one death in the T-Tx group. No other RAI-L-ABL patients had detectable disease, whereas patients in the C-Tx group and two patients in the T-Tx group had detectable disease (p=0.18). Long-term stimulated or suppressed Tg of <1 ng/mL were found in 87.5% of the RAI-L-ABL group (n=28), 86.3% of the C-Tx group (n=57), and 77.8% of the T-Tx group (n=21). Tg was detectable in 40.6% of the RAI-L-ABL group compared to 13.8% of C-Tx and 28.6% of T-Tx groups (p<0.05, between groups).

CONCLUSIONS

RAI-L-ABL, C-Tx, and T-Tx are equally effective in achieving serum TSH concentrations of >25 mIU/L and preparing patients for conventional (131)I treatment and whole body scanning with similar long-term outcomes. However, persistent measurable Tg (range 0.2-2.2 ng/mL) is more common after RAI-L-ABL.