Sarimar Agosto Salgado, MD
Moffitt Cancer Center
Tampa, Florida
September 23, 2022

The mainstays of therapy for differentiated thyroid cancer cases include surgery, selective use of radioactive iodine (RAI) based on risk of tumor recurrence, and TSH suppression therapy with levothyroxine[1]. Although most patients have a favorable prognosis, a subset develop distant metastases (<10%), of which approximately two-thirds result in radioactive iodine refractory differentiated thyroid cancer (RAIR-DTC) [2]. Depending on the extent of metastatic disease, active surveillance under TSH suppression and localized therapies, including surgery, radiation, ablative therapies, and bone modulating agents for bone metastases, may assist in controlling the disease. Nevertheless, patients may require long-term systemic treatment for progressive RAIR-DTC. Evaluation for systemic therapy includes radiographic staging (including brain imaging), tumor testing for targetable mutations, comprehensive laboratories, cardiac function assessment, and close monitoring of comorbidities such as hypertension, diabetes, etc.

Initial systemic therapies approved for RAIR-DTC included multikinase inhibitors (MKIs) Lenvatinib and Sorafenib, which target multiple tumorigenic kinase pathways, including vascular endothelial growth factor receptors. Lenvatinib demonstrated impressive response rates of 65% and survival improvement in patients 65 years and older, leading to FDA approval in 2015 [3-5]. However, since tumors almost inevitably develop resistance mechanisms, additional therapies are being studied to expand the management options for RAIR-DTC; for example, Cabozantinib has recently been approved as a second line MKI [6].

Improved understanding of the molecular pathogenesis of thyroid cancer, coupled with increasingly comprehensive molecular testing platforms, has led to new insights. In fact, molecular testing has developed over time into an informative tool for prognostic and therapeutic implications. For example, BRAF V600E is the most common alteration in papillary thyroid cancer (PTC), present in at least 60% of cases [7]. BRAF inhibitors alone (e.g., Dabrafenib) or in combination with a MEK inhibitor (e.g., Trametinib) have shown overall responses between 42-54% in RAIR-DTC [8, 9]. A recent FDA approval in the summer of 2022, supported dabrafenib and trametinib combination for unresectable or metastatic BRAF V600E solid tumors with progression despite prior treatments. In addition, recently approved selective inhibitor options include Selpercatinib and Pralsetinib for RET fusion-driven thyroid cancer, and Larotrectinib and Entrectinib for tumors harboring NTRK fusions. Together, both MKI’s and selective inhibitors have brought a ray of hope for patients with RAIR-DTC[10]. However, practice variability still exists in terms of a) timing of initiation of systemic therapy, b) the definition criteria for RAI-refractory thyroid cancer, and c) decision regarding the first line of therapy when a targetable mutation is present.

Selective targeted therapies balance efficacy and tolerability, leading to new potential approaches to manage advanced thyroid cancer. A promising new strategy leverages the discovery that BRAF V600E mutations can lead to alteration-dysfunction in the sodium-iodine symporter and contribute to the development of RAIR-DTC. A short course of BRAF-inhibitor therapy may result in redifferentiation in BRAF-altered tumors; this is a promising approach to resensitize tumors to RAI, allowing for discontinuation of systemic therapy post-RAI and thereby limiting the toxicities of long-term chemotherapy [11, 12]. Similar capacity for redifferentiation has been reported in RAS altered, NTRK, or RET fusion-driven thyroid cancers after the treatment with a MEK inhibitor, Larotrectinib, and Selpercatinib, respectively [13-16]. Further studies are needed to determine the optimal candidates by molecular signature, standardization of protocols, and appropriate timing to implement a redifferentiation approach.

As an oncologic endocrinologist, given the evolving landscape of therapeutic options for RAIR-DTC, it is essential to highlight the importance of timely evaluating patients with advanced thyroid cancer. High-risk thyroid cancer patients should be referred to expert multidisciplinary patient-centered teams; this ensures patients receive a comprehensive assessment to delineate treatment plans and incorporate the use of precision oncology.

References:
1. Haugen, B.R., et al., 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): p. 1-133.
2. Fullmer, T., M.E. Cabanillas, and M. Zafereo, Novel Therapeutics in Radioactive Iodine-Resistant Thyroid Cancer. Front Endocrinol (Lausanne), 2021. 12: p. 720723.
3. Schlumberger, M., et al., Lenvatinib versus placebo in radioiodine-refractory thyroid cancer. N Engl J Med, 2015. 372(7): p. 621-30.
4. Brose, M.S., et al., Effect of Age on the Efficacy and Safety of Lenvatinib in Radioiodine-Refractory Differentiated Thyroid Cancer in the Phase III SELECT Trial. J Clin Oncol, 2017. 35(23): p. 2692-2699.
5. Brose, M.S., et al., Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. Lancet, 2014. 384(9940): p. 319-28.
6. Brose, M.S., et al., Cabozantinib for radioiodine-refractory differentiated thyroid cancer (COSMIC-311): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol, 2021. 22(8): p. 1126-1138.
7. Landa, I., et al., Genomic and transcriptomic hallmarks of poorly differentiated and anaplastic thyroid cancers. J Clin Invest, 2016. 126(3): p. 1052-66.
8. Shah, M.H., et al., Results of randomized phase II trial of dabrafenib versus dabrafenib plus trametinib in BRAF-mutated papillary thyroid carcinoma. Journal of Clinical Oncology, 2017. 35(15_suppl): p. 6022-6022.
9. Busaidy, N.L., et al., Dabrafenib Versus Dabrafenib + Trametinib in BRAF-Mutated Radioactive Iodine Refractory Differentiated Thyroid Cancer: Results of a Randomized, Phase 2, Open-Label Multicenter Trial. Thyroid, 2022.
10. Cabanillas, M.E., M. Ryder, and C. Jimenez, Targeted Therapy for Advanced Thyroid Cancer: Kinase Inhibitors and Beyond. Endocr Rev, 2019. 40(6): p. 1573-1604.
11. Dunn, L.A., et al., Vemurafenib Redifferentiation of BRAF Mutant, RAI-Refractory Thyroid Cancers. J Clin Endocrinol Metab, 2019. 104(5): p. 1417-1428.
12. Rothenberg, S.M., et al., Redifferentiation of iodine-refractory BRAF V600E-mutant metastatic papillary thyroid cancer with dabrafenib. Clin Cancer Res, 2015. 21(5): p. 1028-35.
13. Groussin, L., J. Clerc, and O. Huillard, Larotrectinib-Enhanced Radioactive Iodine Uptake in Advanced Thyroid Cancer. N Engl J Med, 2020. 383(17): p. 1686-1687.
14. Lee, Y.A., et al., NTRK and RET fusion-directed therapy in pediatric thyroid cancer yields a tumor response and radioiodine uptake. J Clin Invest, 2021. 131(18).
15. Ho, A.L., et al., Selumetinib-enhanced radioiodine uptake in advanced thyroid cancer. N Engl J Med, 2013. 368(7): p. 623-32.
16. Jaber, T., et al., Targeted Therapy in Advanced Thyroid Cancer to Resensitize Tumors to Radioactive Iodine. J Clin Endocrinol Metab, 2018. 103(10): p. 3698-3705.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

We invite you to submit any questions or comments regarding this blog post below, for potential response in a future blog or social media post.

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Sara Ahmadi, MD, ECNU
Brigham and Women’s Hospital
Boston, MA
November 19, 2021

Thyroid nodules and thyroid cancer are common clinical problems in adults. The yearly incidence of thyroid cancer in the United States has almost tripled from 4.9 per 100,000 in 1975 to 14.3 per 100,000 in 2009. It has been predicted that thyroid cancer will replace colorectal cancer as the fourth leading cancer diagnosis by 2030(1,2).

Surgery is the primary treatment for thyroid cancer. Most patients with differentiated thyroid cancer have an excellent outcome with a 98% long-term disease-specific survival.

Traditional therapy with total thyroidectomy and radioactive iodine(RAI) has not shown added benefit in patients with low-risk differentiated thyroid cancer and might result in more harm. Thyroid lobectomy, selective use of radioactive iodine, and active surveillance have gained attention in recent years. They have been recommended as potential management options for low-risk thyroid cancer and micropapillary thyroid cancer in the current American Thyroid Association guidelines(2). This has led to significant changes in clinical practice. A study of 35,291 patients using National Surgery Quality Improvement Program Data showed that there has been a 10-fold increase in the rate of thyroid lobectomy rather than total thyroidectomy after the publication of 2015 ATA guidelines(3).

However, many patients with differentiated thyroid cancer may overestimate the mortality implications, which may drive their willingness to undergo more aggressive treatment(4).

The Discrete Choice Survey Study of a cohort of 150 patients with newly diagnosed differentiated thyroid cancer or thyroid nodule requiring surgery showed that risk of thyroid cancer recurrence impacted patient’s preference around surgical treatment options the most, followed by risk of requiring completion thyroidectomy and recurrent laryngeal nerve injury. The risk of hypocalcemia and hypothyroidism had the least impact on patients’ preferences around treatment options. This study also showed that the average patient would prefer total thyroidectomy unless the risk of requiring completion thyroidectomy can be reduced to 30% or less(5).

Patients’ concern and worry can also limit their acceptability of less aggressive treatment options. A survey of 243 patients with papillary thyroid cancer enrolled in an active surveillance program showed cancer worry is common among these patients. However, the patient’s level of concern improves over time(6).

Patient-physician communication also plays an essential role in providing the patient with a good understanding of the risks and benefits of different treatment options and an informed decision-making process. Computerized patient decision aids in addition to usual care can be associated with a significant increase in patients’ medical knowledge around treatment options and a reduction in decisional conflict at the time of decision making(7). In a recent study, 1319 patients with thyroid cancer in whom selective use of radioactive iodine was recommended were surveyed to assess patient perspectives regarding RAI decision making. More than half of the patients perceived they did not have a choice regarding RAI. These patients were also more likely to receive RAI and to have lower decision satisfaction(8).

There has been a significant change in clinical practice since the publication of the 2015 ATA guidelines. It is of vital importance that we improve our understanding of patients’ preferences, ensure excellent patient-physician communication, and use educational decision aids in conjunction with physician counseling to facilitate shared-decision making.

References:
1. Rahib L, Smith BD, Aizenberg R, Rosenzweig AB, Fleshman JM, Matrisian LM. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer research. 2014;74(11):2913-2921.
2. Haugen BR, Alexander EK, Bible KC, et al. 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 : official journal of the American Thyroid Association. 2016;26(1):1-133.
3. Ullmann TM, Gray KD, Stefanova D, et al. The 2015 American Thyroid Association guidelines are associated with an increasing rate of hemithyroidectomy for thyroid cancer. Surgery. 2019.
4. Dixon PR, Tomlinson G, Pasternak JD, et al. The Role of Disease Label in Patient Perceptions and Treatment Decisions in the Setting of Low-Risk Malignant Neoplasms. JAMA Oncol. 2019.
5. Ahmadi S, Gonzalez JM, Talbott M, et al. Patient Preferences Around Extent of Surgery in Low-Risk Thyroid Cancer: A Discrete Choice Experiment. Thyroid : official journal of the American Thyroid Association. 2020;30(7):1044-1052.
6. Davies L, Roman BR, Fukushima M, Ito Y, Miyauchi A. Patient Experience of Thyroid Cancer Active Surveillance in Japan. JAMA Otolaryngol Head Neck Surg. 2019;145(4):363-370.
7. Sawka AM, Straus S, Rodin G, et al. Thyroid cancer patient perceptions of radioactive iodine treatment choice: Follow-up from a decision-aid randomized trial. Cancer. 2015;121(20):3717-3726.
8. Wallner LP, Reyes-Gastelum D, Hamilton AS, Ward KC, Hawley ST, Haymart MR. Patient-Perceived Lack of Choice in Receipt of Radioactive Iodine for Treatment of Differentiated Thyroid Cancer. J Clin Oncol. 2019;37(24):2152-2161.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

For more information on Thyroid Topics please visit: https://www.thyroid.org/thyroid-information/

We invite you to submit any questions or comments regarding this blog post below, for potential response in a future blog or social media post.

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Matthew Ettleson, MD
University of Chicago Medicine
Chicago, IL
March 16, 2021

The illustrative example of proptosis may be one of the more memorable images in the medical school textbook, but often the more subtle signs and symptoms of thyroid eye disease (also known as Graves’ orbitopathy or ophthalmopathy) can be overlooked. While severe thyroid eye disease is uncommon, up to 40% of patients with Graves’ disease have some signs or symptoms of thyroid eye disease (1). Most patients with mild eye disease have stable symptoms, but those that develop moderate-to-severe disease may benefit from more aggressive therapies, including glucocorticoids and anti-insulin-like growth factor-1 receptor (IGF-1R) therapy.

The diagnosis of thyroid eye disease relies on a focused history and exam of the eyes. Patients may complain of dry eyes or grittiness, excessive tearing, pain with eye movements and blurry or double vision. Patients may present classically with proptosis and lid retraction, but also redness and swelling of the eye lids or conjunctiva may be present. If several of these findings are present, it suggests the patient has active eye disease and thus may be more responsive to medical therapy. Any concern for visual impairment should prompt urgent evaluation by an endocrinologist and ophthalmologist for a more detailed assessment.

What are first steps to take once the diagnosis of thyroid eye disease is made? The patient’s thyroid function should be assessed and, if abnormal, should be treated promptly. Both hyperthyroid and hypothyroid states can contribute to worsening eye disease. For a patient with newly diagnosed Graves’ disease, this usually begins with antithyroid medication followed by more definite therapy, as discussed in the prior blog post by Dr. Oltmann. It is important to note that radioactive iodine (RAI) therapy has been associated with worsening of thyroid eye disease. Thus, RAI therapy should not be given to those with moderate-to-severe eye disease (2). Cigarette smoking has also been associated with progression of eye disease. For some patients, recognizing that smoking leads to worsening eye symptoms may help convince them it’s finally time to quit!

For patients with mild eye disease, local symptom management is key. Treatment strategies include artificial tears, cool compresses, humidifiers, and sunglasses for protection on excessively sunny or windy days. In over 50% of patients with mild eye disease at the time of diagnosis of Graves’ disease, symptoms will resolve over the following 1-2 years (3).

For those with active, moderate-to-severe disease, a course of pulse doses of IV methylprednisolone is first-line therapy, and can be safely done in the clinic. Often, patients will show improvement within the first 4 weeks of treatment, and most will have a good response after 6 months of therapy. Rarely, long-term glucocorticoid therapy is necessary to prevent clinical worsening. The most promising new therapy for moderate-to-severe disease is teprotumumab, a monoclonal antibody against IGF-1R. Teprotumumab was tested in two clinical trials demonstrating significant improvement in those with severe, active eye disease and was recently approved by the FDA for severe thyroid eye disease (4). In patients who do not respond to glucocorticoids, orbital decompression surgery may be necessary. Finally, after thyroidectomy for definitive treatment of Graves’ disease, there can be thyroid eye disease regression in the year following surgery. Therefore, patients may be able to avoid orbital decompression surgery.

Thyroid eye disease is a common complication of Graves’ disease and can contribute significantly to the morbidity of the disease. However, when recognized, thyroid eye disease in most cases can be treated effectively. This is why it’s so important to keep an eye out for thyroid eye disease!

References:
1. Chin YH, Ng CH, Lee MH, Koh JWH, Kiew J, Yang SP, Sundar G, Khoo CM 2020 Prevalence of thyroid eye disease in Graves’ disease: A meta-analysis and systematic review. Clin Endocrinol (Oxf) 93:363-374.
2. Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA 2016 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 26:1343-1421.
3. Tanda ML, Piantanida E, Liparulo L, Veronesi G, Lai A, Sassi L, Pariani N, Gallo D, Azzolini C, Ferrario M, Bartalena L 2013 Prevalence and natural history of Graves’ orbitopathy in a large series of patients with newly diagnosed graves’ hyperthyroidism seen at a single center. J Clin Endocrinol Metab 98:1443-1449.
4. Kahaly GJ 2020 Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 105.

Disclaimer:
The ideas and opinions expressed on the ATA Blogs do not necessarily reflect those of the ATA. None of the information posted is intended as medical, legal, or business advice, or advice about reimbursement for health care services. The mention of any product, service, company, therapy or physician practice does not constitute an endorsement of any kind by ATA. ATA assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of the material contained in, posted on, or linked to this site, or any errors or omissions.

The post Thyroid Health Blog: Keeping an Eye Out for Thyroid Eye Disease appeared first on American Thyroid Association.

CAMBRIDGE, Mass. – Genzyme, a Sanofi company (EURONEXT: SAN and NYSE: SNY), today announced the Food and Drug Administration (FDA) approved revised prescribing information for the use of Thyrogen® (thyrotropin alfa for injection) to widen the dose range of radioiodine (RAI) when used for thyroid remnant ablation. Read More…

THYROGEN^® Highlights of Prescribing Information (PDF File, 666KB)

The post U.S. Prescribing Information for Thyrogen Revised to Include Use of Wider Range of Radioiodine in Patients appeared first on American Thyroid Association.

J. Marti and colleagues from Beth Israel Medical Center and Memorial Sloan-Kettering Cancer Center, New York, NY analyzed more than 13,000 cases of very low risk classical PTC across the U.S. in which patients underwent total thyroidectomy. They report that patterns of RAI use in these patients vary dramatically. Over a 19-year period, the proportion of patients who received RAI ranged from 30-36%.

In a presentation entitled “Overutilization of RAI for Very Low Risk Thyroid Cancer Is Most Frequent in Regions with Poorer Healthcare Access,” the researchers describe a composite of socioeconomic factors used to rank the different geographic regions that together are associated with higher use of RAI. These factors include significantly lower levels of income, education, and white collar employment, and higher levels of uninsured, non-English speaking, and poor persons. The people living in these regions have poorer access to health care and, likely, to experienced specialists.

This study will be presented as part of an oral presentation delivered at the 83rd Annual Meeting of the American Thyroid Association, October 16-20, 2013, in San Juan, Puerto Rico.

“Radioiodine therapy has potential toxicity and financial costs, yet a substantial number of low risk thyroid cancer patients receive this therapy despite little to no chance of benefit,” says Ronald J. Koenig, M.D., Ph.D., Program Committee Co-Chair, and Professor, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor. “In order to minimize the overuse of RAI, it is first necessary to identify the factors that lead to this overuse. The study by Marti and colleagues helps to do this, identifying socioeconomic factors that correlate with RAI overuse. Importantly, their data suggest the problem may be inadequate access to appropriate specialists, a problem that should be remediable.”

About the ATA

The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization with over 1,700 members from 43 countries around the world. Celebrating its 90^th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, THYROID, Clinical Thyroidology (CT), VideoEndocrinology and CT for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs through www.thyroid.org; and the development of guidelines for clinical management of thyroid disease. Visit www.thyroid.org for more information.

Media Contact
Bobbi Smith
Executive Director of the American Thyroid Association
Email: thyroid@thyroid.org

The post Overuse of Radioactive Iodine to Treat Low-Risk Thyroid Cancer Is Highest in Regions with Poor Health Care Access appeared first on American Thyroid Association.

ATA guidelines on the management of well-differentiated thyroid cancer currently recommend the routine use of radioactive iodine for the treatment of tumors >4 cm and selective use of radioactive iodine in patients with intrathyroidal disease that is <1 cm or who have evidence of nodal metastases. However, the guidelines recognize that there are conflicting and inadequate data to make firm recommendations for most patients.

A team of researchers led by Iain Nixon, MD, Memorial Sloan Kettering Cancer Center, used the GAMES stratification method to retrospectively analyze 1,129 patients who underwent total thyroidectomy at Memorial Sloan Kettering Cancer Center between 1986 and 2005. They found that select patients with early primary disease (pT1/T2) and low-volume metastatic disease in the neck (pT1/T2 N1) who were managed without radioactive iodine had excellent outcomes. In the group with advanced local disease (pT3/T4), select patients with pT3N0 disease were also safely managed without radioactive iodine. The 5-year disease-specific survival and recurrence-free survival in the pT1/T2N0, pT1/T2N1, and pT3/T4 were 100% and 92%, 100% and 92%, and 98% and 87%, respectively.

“Though radioactive iodine has a place in the treatment of papillary thyroid cancer, new data show that it should not be a blanket treatment for all patients,” said Elizabeth Pearce, MD, of the Boston Medical Center and Program Co-Chair of the ATA annual meeting. “Instead clinicians must make the decision on whether to recommend adjuvant radioactive iodine to manage thyroid cancer.”

About the ATA Annual Meeting 


The 82nd Annual Meeting of the American Thyroid Association will be held Sept. 19-23, in Québec City, Québec, Canada. This four-day creative and innovative scientific program, chaired by Elizabeth Pearce, MD, Boston Medical Center, and Douglas Forrest, PhD, National Institute of Diabetes and Digestive and Kidney Diseases, carefully balances clinical and basic science sessions on the latest advances in thyroidology. The ATA meeting is designed to offer continuing education for endocrinologists, internists, surgeons, basic scientists, nuclear medicine scientists, pathologists, endocrine fellows and nurses, physician assistants and other health care professionals. Visit www.thyroid.org for more information.

About the ATA 


The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization with over 1,600 members from 43 countries around the world. Celebrating its 89th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, THYROID, Clinical Thyroidology and Clinical Thyroidology for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs through www.thyroid.org; and the development of guidelines for clinical management of thyroid disease. Visit www.thyroid.org for more information.

Media Contact 

Bobbi Smith
Executive Director 
of the American Thyroid Association
Email: thyroid@thyroid.org

# # #

The post Radioactive Iodine Treatment Should Be Used in Some but Not All Cases of Papillary Thyroid Cancer appeared first on American Thyroid Association.

“The expected survival time for young patients with differentiated thyroid cancer is long. However, as new data elucidates, a need exists to judiciously weigh the benefits of radioactive iodine against the small, but real, increase in the risk of developing secondary primary malignancies,” said Elizabeth Pearce, MD, of Boston Medical Center, and Program Co-Chair of the ATA Annual Meeting.

Though increasingly used as a treatment for differentiated thyroid cancer, long-term implication of radioactive iodine in children and young adults are not well defined. Existing data are limited to case series with limited follow-up that, in particular, may underestimate the risk of these patients developing secondary primary malignancies. To date, epidemiologic analyses of secondary primary malignancies risk have only been performed in the adult population.

A team of researchers led by Jennifer Marti, MD, of Beth Israel Medical Center in New York, thus sought to characterize of secondary primary malignancies among children. They analyzed 3,850 children and young adult patients (< 25 years old) with differentiated thyroid cancer who were followed in the NCI SEER cancer registry from 1973 to 2008. Among patients who were treated with radioactive iodine, researchers observed 26 cases of secondary primary malignancies, outnumbering the 18.3 cases researchers had expected. Researchers found that patients who were treated with radioactive iodine (40%) had a significantly elevated relative risk (SIR 1.42, p = .05) of developing a secondary primary malignancy at all sites; their risk of developing a salivary malignancy was especially elevated (SIR = 34.12, p < 0.001). Researchers also estimated that over a decade, ~1 in 227 children and young adults will develop a secondary primary malignancy attributed to radioactive iodine treatment and ~1 in 588 will develop a salivary cancer attributable to radioactive iodine treatment. Patients who were not treated with radioactive iodine did not have an elevated risk of developing a secondary primary malignancy.

About the ATA Annual Meeting 


The 82nd Annual Meeting of the American Thyroid Association will be held Sept. 19-23, in Québec City, Québec, Canada. This four-day creative and innovative scientific program, chaired by Elizabeth Pearce, MD, Boston Medical Center, and Douglas Forrest, PhD, National Institute of Diabetes and Digestive and Kidney Diseases, carefully balances clinical and basic science sessions on the latest advances in thyroidology. The ATA meeting is designed to offer continuing education for endocrinologists, internists, surgeons, basic scientists, nuclear medicine scientists, pathologists, endocrine fellows and nurses, physician assistants and other health care professionals. Visit www.thyroid.org for more information.

About the ATA 


The American Thyroid Association (ATA) is the leading worldwide organization dedicated to the advancement, understanding, prevention, diagnosis and treatment of thyroid disorders and thyroid cancer. ATA is an international individual membership organization with over 1,600 members from 43 countries around the world. Celebrating its 89th anniversary, ATA delivers its mission through several key endeavors: the publication of highly regarded monthly journals, THYROID, Clinical Thyroidology and Clinical Thyroidology for Patients; annual scientific meetings; biennial clinical and research symposia; research grant programs for young investigators, support of online professional, public and patient educational programs through www.thyroid.org; and the development of guidelines for clinical management of thyroid disease. Visit www.thyroid.org for more information.

Media Contact 

Bobbi Smith
Executive Director
 of the American Thyroid Association
Email: thyroid@thyroid.org

# # #

The post Children, Young Adults Treated with Radioactive Iodine at Elevated Risk of Developing Secondary Primary Cancer appeared first on American Thyroid Association.

Que es la glandula tiroides?

La glandula tiroides localizada en el cuello, produce las hormonas tiroideas que ayudan al cuerpo a utilizar energia, mantener la temperatura corporal y a que el cerebro, el corazon, los musculos y otros organos funcionen normalmente.

La glandula tiroides y el iodo

El iodo es escencial para el funcionamiento apropiado de la glandula tiroides, el cual es utilizado para producir las hormonas tiroideas. La glandula tiroides esta equipada con un sistema activo o “bomba” para movilizar el iodo hacia dentro de las celulas tiroideas, donde se concentra como ioduro.

Que es el iodo radioactive (RAI)?

El iodo, en la forma de ioduro, se convierte en dos isotopos radioactivos comunmente utilizados en pacientes con enfermedades tiroideas: I-123 (no produce daño a las celulas tiroideas) y I-131 (destruye las celulas tiroideas). El RAI es seguro para ser utilizado en individuos alergicos a pescados y/o derivados y/o a agentes de contraste iodados. El RAI se administra via oral ya sea en pildoras o en forma liquida.

RAI para imagenes tiroideas

El I-123 es el isotopo usual para tomar imagenes y determiner la actividad de la glandula tiroidea intacta (Centellograma tiroideo y Captacion tiroidea de iodo radioactivo, RAIU), debido a que es inocuo para las celulas tiroideas. No se precisan precauciones especiales para radiacion luego de un centellograma o RAIU con I-123.

RAI para tratamiento de alteraciones tiroideas

Tejido tiroideo normal- El I-131 se indica para destruir tejido glandular hiperfuncionante (ver el folleto de Hipertiroidismo) o para disminuir el tamaño de glandulas tiroideas que funcionan normalmente pero causan problemas debido a su tamaño (ver el folleto de Bocio). El I-131 puede ocasionalmente causar dolor leve en el cuello, que puede ser tratado con aspirina, ibuprofeno o acetaminofeno. El tratamiento con RAI puede tomar algunos meses para lograr el efecto deseado.

Cancer de tiroides- grandes dosis de I-131 se utilizan para destruir la celulas del cancer de tiroides (ver el folleto de Cancer de tiroides). Este se indica luego que el remanente de tejido tiroideo (incluyendo cualquier celula cancerosa) es estimulado aumentando los niveles de TSH ya sea suspendiendo el tratamiento con hormona tiroidea o utilizando TSH recombinante humana Dependiendo de las reglamentaciones de cada estado, los pacientes pueden tener que permanecer aislados en el hospital por 24 hs. para evitar la exposicion de otros individuos a la radiacion, especialmente si son niños pequeños que viven en la misma casa.

Medidas de seguridad luego del tratamiento con I-131

Debido a que el RAI produce radiacion, los pacientes debe esforzarse para evitar exponer a la misma a otras personas, particularmente a mujeres embarazadas y niños pequeños. La cantidad de radiacion marcadamente disminuye cuanto mas aumenta la distancia con el paciente. Aquellos pacientes que necesitan viajar en los dias posteriores a recibir el tratamiento con I-131 deben llevar una carta de su medico explicando el tratamiento recibido debido a que los detectores de radiacion de los aeropuertos o de los edificios federales pueden captar pequeños niveles de radiacion.

Riesgos del I-131 RAI a largo plazo

En general, el RAI es un tratamiento seguro y efectivo. El hipotiroidismo es un efecto secundario frecuente del RAI utilizado para el hipertiroidismo y siempre se observa luego del tratamiento con RAI para el cancer de tiroides (ver el folleto de Hipotiroidismo). Algunos estudios sugieren un sutil incremento de cancer de tiroides luego del tratamiento con RAI para hipertiroidismo. Tambien puede observarse perdida del gusto y lboca seca debido al daño de las glandulas salivales. El uso de gotas de limon, Vitamina C o estimulacion con compuestos amargos para potencialmente disminuir la exposicion de las glandulas salivales al RAI es controvertido y deberia ser discutido con su medico. Es muy importante una vez que Ud. ha sido tratado con RAI, tenga un seguimiento regular de por vida con su medico.

Precauciones especiales para mujeres

El RAI, ya sea I-123 o I-131, nunca debe ser utilizado en una paciente embarazada o que se encuentra amamantando. El embarazo debe posponerse por lo menos por 6 – 12 meses luego del tratamiento con I-131 debido a que los ovarios estan expuestos a la radiacion luego del tratamiento y para asegurarnos que los niveles de las hormonas tiroideas esten estables antes del embarazo. No hay evidencia clara que el RAI sea causa de infertilidad.

Precauciones especiales para hombres

Los hombres que reciben tratamiento con RAI por cancer de tiroides pueden presentar disminucion en el conteo de esperma e infertilidad temporaria por un periodo aproximado de dos años. La criopreservacion de esperma es una opcion valida en un paciente que puede llegar a recibir varias dosis RAI por cancer de tiroides.

Informacion adicional

Mas detalles sobre este y otro temas relacionados estan disponibles en la seccion informacion para pacientes del sitio web de la American Thyroid Association www.thyroid.org.

Iodo Radioactivo FAQ para guardar e imprimir (PDF File, 264 KB)

Iodo Radioactivo FAQ para guardar e imprimir (PDF File, 144 KB)

The post FAQ: Iodo Radioactivo appeared first on American Thyroid Association.

Qué es la glandula tiroides?

La glandula tiroides tiene forma de mariposa y normalmente se localiza en la parte de adelante del cuello, su trabajo es formar las hormonas tiroideas, volcarlas al torrente sanguineo y entregarla a todos los tejidos del cuerpo.

Las hormonas tiroideas ayudan al cuerpo a utilizar energia, mantener la temperatura corporal y a que el cerebro, el corazon, los musculos y otros organos funcionen normalmente.

La glandula tiroides y el iodo

El iodo es escencial para el funcionamiento apropiado de la glandula tiroides, el cual es utilizado para producir las hormonas tiroideas. La glandula tiroides esta equipada con un sistema activo o "bomba" para movilizar el iodo hacia dentro de las celulas tiroideas, donde se concentra como ioduro. La glandula tiroides es el unico tejido del organismo que capta iodo y lo almacena como ioduro.

Que es el iodo radioactive (RAI)?

El iodo, en la forma de ioduro, se convierte en dos isotopos radioactivos comunmente utilizados en pacientes con enfermedades tiroideas: I-123 (no produce daño a las celulas tiroideas) y I-131 (destruye las celulas tiroideas). El RAI es seguro para ser utilizado en individuos alergicos a pescados y/o derivados y/o a agentes de contraste iodados. El RAI se administra via oral ya sea en pildoras o en forma liquida.

RAI para imagenes tiroideas

El I-123 es el isotopo usual para tomar imagenes y determiner la actividad de la glandula tiroidea intacta (Centellograma tiroideo y Captacion tiroidea de iodo radioactivo, RAIU), debido a que es inocuo para las celulas tiroideas. No se precisan precauciones especiales para radiacion luego de un centellograma o RAIU con I-123.

RAI para tratamiento de alteraciones tiroideas

Tejido tiroideo normal– El I-131 se indica para destruir tejido glandular hiperfuncionante (ver el folleto de Hipertiroidismo) o para disminuir el tamaño de glandulas tiroideas que funcionan normalmente pero causan problemas debido a su tamaño (ver el folleto de Bocio). El I-131 puede ocasionalmente causar dolor leve en el cuello, que puede ser tratado con aspirina, ibuprofeno o acetaminofeno. El tratamiento con RAI puede tomar algunos meses para lograr el efecto deseado.

Cancer de tiroides– grandes dosis de I-131 se utilizan para destruir la celulas del cancer de tiroides (ver el folleto de Cancer de tiroides). Este se indica luego que el remanente de tejido tiroideo (incluyendo cualquier celula cancerosa) es estimulado aumentando los niveles de TSH ya sea suspendiendo el tratamiento con hormona tiroidea o utilizando TSH recombinante humana Dependiendo de las reglamentaciones de cada estado, los pacientes pueden tener que permanecer aislados en el hospital por 24 hs. para evitar la exposicion de otros individuos a la radiacion, especialmente si son niños pequeños que viven en la misma casa.

Medidas de seguridad luego del tratamiento con I-131

Debido a que el RAI produce radiacion, los pacientes debe esforzarse para evitar exponer a la misma a otras personas, particularmente a mujeres embarazadas y niños pequeños. La cantidad de radiacion marcadamente disminuye cuanto mas aumenta la distancia con el paciente. Aquellos pacientes que necesitan viajar en los dias posteriores a recibir el tratamiento con I-131 deben llevar una carta de su medico explicando el tratamiento recibido debido a que los detectores de radiacion de los aeropuertos o de los edificios federales pueden captar pequeños niveles de radiacion.

Riesgos del I-131 RAI a largo plazo

En general, el RAI es un tratamiento seguro y efectivo. El hipotiroidismo es un efecto secundario frecuente del RAI utilizado para el hipertiroidismo y siempre se observa luego del tratamiento con RAI para el cancer de tiroides (ver el folleto de Hipotiroidismo). Algunos estudios sugieren un sutil incremento de cancer de tiroides luego del tratamiento con RAI para hipertiroidismo. Tambien puede observarse perdida del gusto y lboca seca debido al daño de las glandulas salivales. El uso de gotas de limon, Vitamina C o estimulacion con compuestos amargos para potencialmente disminuir la exposicion de las glandulas salivales al RAI es controvertido y deberia ser discutido con su medico. Es muy importante una vez que Ud. ha sido tratado con RAI, tenga un seguimiento regular de por vida con su medico.

Precauciones especiales para mujeres

El RAI, ya sea I-123 o I-131, nunca debe ser utilizado en una paciente embarazada o que se encuentra amamantando. De esta manera protegemos al bebe , ya que Si no recibiria leche.

Radioactiva proveniente de las mamas que concentran iodo

El amamantamiento debe detenerse por lo menos 6 semanas antes de la administarcion del iodo y no debe reiniciarse luego de haberlo recibido. Pero si se podra amamantar en forma segura en embarazos futuros.

El embarazo debe posponerse por lo menos por 6 – 12 meses luego del tratamiento con I-131 debido a que los ovarios estan expuestos a la radiacion luego del tratamiento y para asegurarnos que los niveles de las hormonas tiroideas esten estables antes del embarazo. No hay evidencia clara que el RAI sea causa de infertilidad.

Precauciones especiales para hombres

Los hombres que reciben tratamiento con RAI por cancer de tiroides pueden presentar disminucion en el conteo de esperma e infertilidad temporaria por un periodo aproximado de dos años. La criopreservacion de esperma es una opcion valida en un paciente que puede llegar a recibir varias dosis RAI por cancer de tiroides.

Further Information

Further details on this and other thyroid- related topics are available in the patient information section on the American Thyroid Association website at www.thyroid.org.

El folleto de Iodo Radioactivo para guardar e imprimir (PDF File, 445 KB)

El folleto de Iodo Radioactivo para guardar e imprimir (PDF File, 187 KB)

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Frequently Asked Questions

What is the thyroid gland?

The thyroid gland located in the neck produces thyroid hormones which help the body use energy, stay warm and keep the brain, heart, muscles, and other organs working normally.

Why is iodine used in some thyroid gland treatment?

Iodine is essential for proper function of the thyroid gland, which uses it to make the thyroid hormones. The thyroid is equipped with an active system or “pump” for moving iodine into its cells, where it is concentrated as iodide.

What is radioactive iodine (RAI)?

Iodine, in the form of iodide, is made into two radioactive isotopes that are commonly used in patients with thyroid diseases: I-123 (harmless to thyroid cells) and I-131 (destroys thyroid cells. RAI is safe to use in individuals who have had allergic reactions to seafood or X-ray contrast agents. RAI is given by mouth in pill or liquid form.

Does RAI for thyroid imaging provide the best results?

I-123 is the usual isotope used to take pictures and determine the activity of the intact thyroid gland (Thyroid Scan and Radioactive Iodine Uptake, RAIU), since it is harmless to thyroid cells. No special radiation precautions are necessary after a thyroid scan or RAIU with I-123.

When is RAI used for treatment of thyroid disorders?

Normal Thyroid Tissue – I-131 is given to destroy overactive thyroid tissue (see Hyperthyroidism brochure) or to shrink thyroid glands that are functioning normally but are causing problems because of their size (see Goiter brochure). I-131 may occasionally cause mild pain in the neck that can be treated with aspirin, ibuprofen or acetaminophen. The RAI treatment may take up to several months to have its effect.

Thyroid Cancer – Large doses of I-131 are used to destroy thyroid cancer cells (see Thyroid Cancer brochure). This is performed after the remaining thyroid tissue (including any cancer cells) is stimulated by raising TSH levels by either withdrawing thyroid hormone or by treating with recombinant human TSH. Depending on state regulations, patients may have to stay isolated in the hospital for about 24 hours to avoid exposing other people to radiation, especially if there are young children living in the same home.

What are the radiation safety precautions after treatment with I-131 RAI?

Since RAI produces radiation, patients must do their best to avoid radiation exposure to others, particularly to pregnant women and small children. The amount of radiation exposure markedly decreases as the distance from the patient increases. Patients who need to travel in the days after I-131 RAI treatment are advised to carry a letter of explanation from their physician since radiation detection devices used at airports or in federal buildings may pick up even very small radiation levels.

Are there long term risks of I-131 RAI?

In general, RAI is a safe and effective treatment. Hypothyroidism is a common side effect of RAI for hyperthyroidism and always seen after RAI for thyroid cancer (see Hypothyroidism brochure). Some studies suggest a slight increase in thyroid cancers after RAI treatment for hyperthyroidism. Loss of taste and dry mouth due to salivary gland damage may be seen. The use of lemon drops, vitamin C or sour stimulation to potentially decrease the exposure of the salivary glands to RAI is controversial and should be discussed with your physician. Importantly, once you have been treated with RAI, regular medical follow-up is lifelong.

What are the special concerns for women?

RAI, whether I-123 or I-131, should never be used in a patient who is pregnant or nursing. Pregnancy should be put off until at least 6 – 12 months after I-131 RAI treatment since the ovaries are exposed to radiation after the treatment and to ensure that thyroid hormone levels are normal and stable prior to pregnancy. There is no clear evidence that RAI leads to infertility.

Are there special concerns for men?

Men who receive RAI treatment for thyroid cancer may have decreased sperm counts and temporary infertility for periods of roughly two years. Sperm banking is an option in a patient who is expected to need several doses of RAI for thyroid cancer.

Where can I find additional information?

Further details on this and other thyroid-related topics are available in the patient information section on the American Thyroid Association website at www.thyroid.org.

Radioactive Iodine FAQ for Saving and Printing (PDF File, 263 KB)

Radioactive Iodine FAQ for Saving and Printing (PDF File, 263 KB)

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