Selective use of RAI for ablation and adjuvant therapy after total thyroidectomy for differentiated thyroid cancer: A practical approach to clinical decision making

Abstract

For the past 40 years, many clinicians have recommended RAI remnant ablation for essentially all differentiated thyroid cancer patients with a primary tumor size greater than 1.5 cm or with any evidence of even microscopic disease outside the thyroid capsule. This "one size fits all" approach exposes many low risk thyroid cancer patients to the risks of ionizing radiation with little potential benefit. Current thyroid cancer management guidelines call for a far more risk adapted approach to the selection of patients for post-operative RAI treatment. We will review the current selective use of RAI ablation recommendations and provide a practical approach to implementation of a risk adapted approach to post-operative RAI administration. We will show how thoughtful integration of pre-operative, intra-operative, and post-operative clinico-pathologic factors allows the clinician to accurately identify patients most likely to benefit from RAI administration. This approach ensures that patients most likely to experience a clinical benefit are selected for RAI ablation while avoiding unnecessary exposure to ionizing radiation in the majority of low to intermediate risk thyroid cancer patients.