J Korean Med Assoc.  2004 Dec;47(12):1183-1196. 10.5124/jkma.2004.47.12.1183.

Postoperative Adjuvant Therapy and Follow-Up of Thyroid Carcinoma

• Yi KH

• KMID: 2065214
• DOI: http://doi.org/10.5124/jkma.2004.47.12.1183

Abstract

Differentiated thyroid cancer is usually a curable disease, for which treatment modalities such as surgery, radioiodine, and thyroid hormone have been used for the last 50 years, yet little consensus has been established due to the lack of prospective randomized controlled therapeutic trials. After an initial surgery, the patients' outcome can be predicted by staging classification on the basis of several parameters such as the age of the patient, tumor size, tumor grade or differentiation, presence of local invasion, and regional or distant metastases. However, regardless of the pathologic stage, most patients(except those with micopapillary or minimally invasive follicular carcinomas who underwent only a lobectomies) are supposed to receive radioiodine therapy for ablation of any remnant thyroid tissue, which increases the sensitivity of serum Tg and 131I whole body scan used to detect recurrence or metastasis during a long-term follow-up. Until recently, a high dose of 131I has been preferred, however, low dose therapy(30mCi) is a new trend nowadays, which decreases the incidence of both acute and late complications of radioiodine with the same ablation rate. All patients take thyroid hormone after surgery and radioremnant ablation to suppress the level of serum TSH, which is thought to stimulate tumor cell growth.The T4 dose should be adjusted according to the age of the patient, other medical conditions and the risk of recurrence. During the follow-up, the serum Tg level with anti-Tg antibody and the TSH level and 131I whole body scan should be checked regularly. Recently the serum Tg level stimulated by T4 withdrawal or rhTSH injection is suggested to be the most sensitive marker for the detection of recurrence or metastasis. When the stimulated Tg is undetectable (< 2ng/mL), residual or metastatic cancer can be nearly excluded; when it is higher than 10ng/mL, a high dose 131I therapy and posttherapy 131I whole body scan are needed. In cases where the localization fails(Tg-positive/131I scan-negative cases), other imaging studies such as high-resolution ultrasonography of the neck, spiral CT of chest, bone X-ray or 99mTc-MDP bone scan and 18F-FDG PET scan can be useful. 18F-FDG PET is especially sensitive to detect poorly differentiated thyroid cancers that have lost the ability to uptake radioiodine.

Keyword

Thyroid cancer; Staging; Radioiodine; Thyroid hormone; Follow-up

MeSH Terms

Classification
Consensus
Fluorodeoxyglucose F18
Follow-Up Studies*
Humans
Incidence
Neck
Neoplasm Metastasis
Positron-Emission Tomography
Recurrence
Technetium Tc 99m Medronate
Thorax
Thyroid Gland
Thyroid Neoplasms*
Thyrotropin Alfa
Tomography, Spiral Computed
Ultrasonography
Whole Body Imaging
Fluorodeoxyglucose F18
Technetium Tc 99m Medronate
Thyrotropin Alfa

Reference

1. DeGroot LJ, Kaplan EL, McCormick M, Straus FH. Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab. 1990. 71:414–424.

2. Mazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994. 97:418–428.

3. Gilliand FD, Hunt WC, Orris DM, Key CR. Prognostic factors for thyroid carcinoma : a population based study of 15,698 cases from the surveillance, epidemiology and end results (SEER) program 1973~1991. Cancer. 1997. 79:564–567.

4. Tsang TW, Brierley JD, Simpson WJ, Panzarella T, Gospodarowicz MK, Sutcliffe SB. The effects of surgery, radioiodine and external radiation therapy on the clinical outcome of patients with differentiated thyroid carcinoma. Cancer. 1998. 82:375–388.

5. Greene FL, Page DL, editors. AJCC(American Joint Committee on Cancer) Cancer Staging Manual. 2002. 6th ed. New York: Springer-Verlag;77–79.

6. Ain KB. Papillary thyroid carcinoma : etiology, assessment, and therapy. Endocrinol Metab Clin North Am. 1995. 24:711–760.

7. Byar DP, Green SB, Dor P, Williams ED, Colon J, van Glabbeke M, et al. Thyroid Cancer Cooperative Group. A prognostic index for thyroid carcinoma : a study of the E.O.R.T.C. Eur J Cancer. 1979. 15:1033–1034.

8. Hay ID, Grant CS, Taylor WF, McConahey WM. Ipsilateral lobectomy versus bilateral lobar resection in papillary thyroid carcinoma : a retrospective analysis of surgical outcome using a novel prognostic scoring system. Surgery. 1987. 102:1088–1095.

9. Cady B, Rossi R. An expanded view of risk-group definition in differentiated thyroid carcinoma. Surgery. 1988. 104:947–953.

10. Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS. Predicting outcome in papillary thyroid carcinoma : development of a reliable prognostic scoring system in a cohort of 1,779 patients surgically treated at one institution during 1940 through 1989. Surgery. 1993. 114:1050–1058.

11. Shaha AR, Loree TR, Shah JP. Prognostic factors and risk group analysis in follicular carcinoma of the thyroid. Surgery. 1995. 118:1131–1138.

12. Sherman SI, Brierley JD, Sperling M, Ain KB, Blgos ST, Maxon HR 3rd, et al. National Thyroid Cancer Treatment Cooperative Study Registry Group. Prospective multicenter study of thyroid carcinoma treatment : initial analysis of staging and outcome. Cancer. 1998. 83:1012–1021.

13. Dulgeroff AJ, Hershman JM. Medical therapy for differentiated thyroid carcinoma. Endocr Rev. 1994. 15:500–515.

14. Burman KD. How serious are the risks of thyroid hormone over-replacement? Thyroid Today. 1995. 18:1–9.

15. Cobin RH. Thyroid hormone excess and bone. a clinical review. Endocr Pract. 1995. 1:404–409.

16. Sawin CT, Geller A, Wolf PA, Belanger AJ, Baker E, D'Agostino RB, et al. Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. 1994. 331:1249–1245.

17. Mazzaferri EL. An overview of the management of papillary and follicular thyroid carcinoma. Thyroid. 1999. 9:421–427.

18. Schlumberger M, Mancusi F, Baudin E, Pacini F. 131-I therapy for elevated thyroglobulin levels. Thyroid. 1997. 7:273–276.

19. Wartofsky L, Sherman SI, Gopal J, Schlumberger M, Hay ID. The use of radioactive iodine in patients with papillary and follicular thyroid cancer. J Clin Endocrinol Metab. 1998. 83:4195–4199.

20. Mazzaferri EL. Thyroid remnant ¹³¹I ablation for papillary and follicular thyroid carcinoma. Thyroid. 1997. 7:265–271.

21. Solomon BL, Wartofsky L, Burman KD. Currents trends in the management of well differentiated papillary thyroid carcinoma. J Clin Endocrinol Metab. 1996. 81:333–339.

22. Brierley J, Maxon HR. Fagin JA, editor. Radioiodine and external radiation therapy. Thyroid cancer. 1998. Boston/Dordrecht London: Kluwer Academic Publishers;285–317.

23. Pacini F, Molinaro E, Castagna MG, Agate L, Elisei R, Pinchera A, et al. Recombinant human thyrotropin-stimulated serum thyroglobulin combined with neck ultrasonography has the highest sensitivity in monitoring differentiated thyroid carcinoma. J Clin Endocrinol Metab. 2003. 88:3668–3673.

24. DeGroot LJ, Reilly M. Comparison of 30-and 50-mCi doses of iodine-131 for thyroid ablation. Ann Intern Med. 1982. 96:51–53.

25. Johansen K, Woodhouse NJ, Odugbesan O. Comparison of 1,073 MBq and 3,700 MBq iodine-131 in postoperative ablation of thyroid tissue in patients with differentiated thyroid cancer. J Nucl Med. 1991. 32:252–254.

26. Beierwaltes WH, Rabbani R, Dmuchowski C, Lloyd RV, Eyre P, Mallette S. An analysis of "ablation of thyroid remnants" with I-131 in 511 patients from 1947~1984 : Experience at University of Michigan. J Nucl Med. 1984. 25:1287–1293.

27. Maxon HR, Englaro EE, Thomas SR, Hertzberg VS, Hinnefeld JD, Aden MD, et al. Radioiodine-131 therapy for well-differentiated thyroid cancer-a quantitative radiation dosimetric approach : Outcome and validation in 85 patients. J Nucl Med. 1992. 33:1132–1136.

28. Park HM, Perkins OW, Edmondson JW, Schnute RB, Manatunga A. Influence of diagnostic radioiodines on the uptake of ablative dose of iodine-131. Thyroid. 1994. 4:49–54.

29. Haugen BR, Pacini F, Reiners C, Schlumberger M, Ladenson PW, Ridgway EC, et al. A comparison of recombinant human thyrotropin and thyroid hormone withdrawal for the detection of thyroid remnant or cancer. J Clin Endocrinol Metab. 1999. 84:3877–3885.

30. Robbins RJ, Tuttle M, Sonenberg M, Shaha A, Sharaf R, Larson SM, et al. Radioiodine ablation of thyroid remnants after preparation with recombinant human thyrotropin. Thyroid. 2001. 11:865–869.

31. Koong SS, Reynolds JC, Movius EG, Keenan AM, Ain KB, Robbins J, et al. Lithium as a potential adjuvant to ¹³¹I therapy of metastatic, well differentiated thyroid carcinoma. J Clin Endocrinol Metab. 1999. 84:912–916.

32. Burmeister LA, duCret RP, Mariash CN. Local reactions to radioiodine in the treatment of thyroid cancer. Am J Med. 1991. 90:217–222.

33. Alexander C, Bader JB, Schaefer A, Finke C, Kirsch CM. Intermediate and long-term side effects of high-dose radioiodine therapy for thyroid carcinoma. J Nucl Med. 1998. 39:1551–1554.

34. Creutzig H. Sialadenitis following iodine-131 therapy for thyroid carcinoma. J Nucl Med. 1985. 26:816–817.

35. Datz FL. Cerebral edema following iodine-131 therapy for thyroid carcinoma metastatic to the brain. J Nucl Med. 1986. 27:637–640.

36. Sweeney DC, Johnson GS. Radioiodine therapy for thyroid cancer. Endocrinol Metab Clin North Am. 1995. 24:803–839.

37. Chiu AC, Delpassand ES, Sherman SI. Prognosis and treatment of brain metastases in thyroid carcinoma. J Clin Endocrinol Metab. 1997. 82:3637–3642.

38. Van Nostrand D, Neutze J, Atkins F. Side effects of "rational dose" iodine-131 therapy for metastatic well-differentiated thyroid carcinoma. J Nucl Med. 1986. 27:1519–1527.

39. Raymond JP, Izembart M, Marliac V, Dagousset F, Merceron RE, Vallee G, et al. Temporary ovarian failure in thyroid cancer patients after thyroid remnant ablation with radioactive iodine. J Clin Endocrinol Metab. 1989. 69:186–190.

40. Vini L, Hyer S, Al-Saadi A, Prztt B, Harmer C. Prognosis for fertility and ovarian function after treatment with radioiodine for thyroid cancer. Postgrad Med J. 2002. 78:92–93.

41. Edmonds CJ, Smith T. The long-term hazards of the treatment of thyroid cancer with radioiodine. Br J Radiol. 1986. 59:45–51.

42. Pacini F, Gasperi M, Fugazzola L, Ceccarelli C, Lippi F, Pinchera A, et al. Testicular function in patients with differentiated thyroid carcinoma treated with radioiodine. J Nucl Med. 1994. 35:1418–1422.

43. Sarkar SD, Beierwaltes WH, Gill SP, Cowley BJ. Subsequent fertility and birth histories of children and adolescents treated with ¹³¹I for thyroid cancer. J Nucl Med. 1976. 17:460–464.

44. Maxon H III. The role of I-131 in the treatment of thyroid cancer. Thyroid Today. 1993. 16:1–9.

45. Maxon H III, Smith HS. Radioiodine-131 in the diagnosis and treatment of metastatic well differentiated thyroid cancer. Endocrinol Metab Clin North Am. 1990. 19:685–718.

46. Wong JB, Kaplan MM, Meyer KB, Pauker SG. Ablative radioactive iodine therapy for apparently localized thyroid carcinoma. A decision analytic perspective. Endocrinol Metab Clin North Am. 1990. 19:741–746.

47. Maheshwari YK, Hill CS Jr, Haynie TP 3rd, Hickey RC, Samaan NA. ¹³¹I therapy in differentiated thyroid carcinoma : M.D. Anderson Hospital experience. Cancer. 1981. 47:664–671.

48. Brown AP, Greening WP, McCready VR, Shaw HJ, Harmer CL. Radioiodine treatment of metastatic thyroid carcinoma : the Royal Marsden Hospital experience. Br J Radiol. 1984. 57:323–327.

49. Simpson WJ, Panzarella T, Carruthers JS, Gospodarowicz MK, Sutcliffe SB. Papillary and follicular thyroid cancer : impact of treatment in 1,578 patients. Int J Radiat Oncol Biol Phys. 1988. 14:1063–1075.

50. Droz JP, Schlumberger M, Rougier P, Ghosn M, Gardet P, Parmentier C. Chemotherapy in metastatic nonanaplastic thyroid cancer : experience at the Institut Gustave-Roussy. Tumori. 1990. 76:480–483.

51. Shimaoka K, Schoenfeld DA, DeWys WD, Creech RH, DeConti R. A randomized trial of doxorubicin versus doxorubicin plus cisplatin in patients with advanced thyroid carcinoma. Cancer. 1985. 56:2155–2160.

52. De Besi P, Busnardo B, Toso S, Girelli ME, Nacamulli D, Fiorentino MV, et al. Combined chemotherapy with bleomycin, adriamycin, and platinum in advanced thyroid cancer. J Endocrinol Invest. 1991. 14:475–480.

53. Santini F, Bottici V, Elisei R, Montanelli L, Mazzeo S, Pacini F, et al. Cytotoxic effects of carboplatinum and epirubicin in the setting of an elevated serum thyrotropin for advanced poorly differentiated thyroid cancer. J Clin Endocrinol Metab. 2002. 87:4160–4165.

54. 2001 AACE/AAES medical/surgical guidelines for clinical practice : management of thyroid carcinoma. Endocr Pract. 2001. 7:202–220.

55. Spencer CA, Takeuchi M, Kazarosyan M, Wang CC, Guttler RB, Nicoloff JT, et al. Serum thyroglobulin autoantibodies prevalence, influence on serum thyroglobulin measurement, and prognostic significance in patients with differentiated thyroid carcinoma. J Clin Endocrinol Metab. 1998. 83:1121–1127.

56. Rubello D, Casara D, Girelli ME, Piccolo M, Busnardo B. Clinical meaning of circulating antithyroglobulin antibodies in differentiated thyroid cancer : a prospective study. J Nucl Med. 1992. 33:1478–1480.

57. Mazzaferri EL, Robbins RJ, Spencer CA, Braverman LE, Pacini F, Pinchera A, et al. A consensus report of the role of serum thyroglobulin as a monitoring method for low-risk patients with papillary thyroid carcinoma. J Clin Endocrinol Metab. 2003. 88:1433–1441.

58. Schlumberger M, Berg G, Cohen O, Duntas L, Jamar F, Wiersinga WM, et al. Follow-up of low-risk patients with differentiated thyroid carcinoma : a European perspective. Eur J Endocrinol. 2004. 150:105–112.

59. Park HM, Perkins OW, Edmondson JW, Schnute RB, Manatunga A. Influence of diagnostic radioiodines on the uptake of ablative dose of iodine-131. Thyroid. 1994. 4:49–54.

60. Schlumberger M, Mancusi F, Baudin E, Pacini F. ¹³¹I therapy for elevated thyroglobulin levels. Thyroid. 1997. 7:273–276.

61. Cailleux AF, Baudin E, Travagli JP, Ricard M, Schlumberger M. Is diagnostic iodine-131 scanning useful after total thyroid ablation for differentiated thyroid cancer? J Clin Endocrinol Metab. 2000. 85:175–178.

62. Antonelli A, Miccoli P, Ferdeghini M, Di Coscio G, Alberti B, Baschieri L, et al. Role of neck ultrasonography in the follow-up of patients operated on for thyroid cancer. Thyroid. 1995. 5:25–28.

63. Naidich DP. Helical computed tomography of the thorax : clinical applications. Radiol Clin North Am. 1994. 32:759–774.

64. Feine U, Lietzenmayer R, Hanke JP, Held J, Wohrle H, Müller-Schauenburg W. Fluorine-18-FDG and iodine-131-iodide uptake in thyroid cancer. J Nucl Med. 1996. 37:1468–1472.

65. Grunwald F, Schomburg A, Bender H, Klemm E, Menzel C, Biersack HJ, et al. Fluorine-18 fluorodeoxyglucose positron emission tomography in the follow-up of differentiated thyroid cancer. Eur J Nucl Med. 1996. 23:312–319.

66. Chung JK, So Y, Lee JS, Choi CW, Lim SM, Cho BY, et al. Value of FDG PET in papillary thyroid carcinoma with negative ¹³¹I whole-body scan. J Nucl Med. 1999. 40:986–992.

67. Petrich T, Borner AR, Otto D, Hofmann M, Knapp WH. Influence of rhTSH on [(18)F]fluorodeoxyglucose uptake by differentiated thyroid carcinoma. Eur J Nucl Med Mol Imaging. 2002. 29:641–647.

68. Wang W, Larson SM, Fazzari M, Tickoo SK, Kolbert K, Robbins RJ, et al. Prognostic value of [18F]fluorodeoxyglucose positron emission tomographic scanning in patients with thyroid cancer. J Clin Endocrinol Metab. 2000. 85:1107–1113.