Radioactive Iodine In Patients Research Articles

Radioactive iodine administration is not associated with improved disease-specific survival in classic papillary thyroid carcinoma greater than 4 cm confined to the thyroid

BackgroundWe aimed to evaluate the impact of radioactive iodine on disease-specific survival in intrathyroidal (N0M0) papillary thyroid carcinoma >4 cm, given conflicting data in the American Thyroid Association guidelines regarding their management. MethodsThe Surveillance, Epidemiology, and End Results database was queried for N0M0 classic papillary thyroid carcinoma >4 cm. Kaplan-Meier estimates were performed to compare disease-specific survival between radioactive iodine-treated and untreated groups. A multivariable Cox regression was performed to identify predictors of disease-specific survival. ResultsThere were more patients aged ≥55 (41.7% vs 32.3%, P = .001) and fewer multifocal tumors (25.3% vs 30.6%, P = .006) in the no radioactive iodine group. Ten-year disease-specific survival was similar between the radioactive iodine treated and untreated groups (97.2% vs 95.6%, P = .34). Radioactive iodine was not associated with a significant disease-specific survival benefit (adjusted hazard ratio = 0.78, confidence interval [0.39–1.58], P = .49). Age ≥55 (adjusted hazard ratio = 3.50, confidence interval [1.69–7.26], P = .001) and larger tumor size (adjusted hazard ratio = 1.04, confidence interval [1.02–1.06], P < .001) were associated with an increased risk of disease-specific death. Subgroup analyses did not demonstrate improved disease-specific survival with radioactive iodine in patients ≥55 and in tumors >5 cm. ConclusionAdjuvant radioactive iodine administration in classic papillary thyroid carcinoma >4 cm confined to the thyroid did not significantly impact disease-specific survival. Thus, these patients may not require routine treatment with adjuvant radioactive iodine.

Comparison of Radioactive Iodine Activities in Terms of Short- and Long-term Results in Ablation Therapy in Patients with Low-risk Differentiated Thyroid Cancer.

The aim of this study was to compare the treatment responses after ablation with 30-50 mCi radioactive iodine (RAI) and 100 mCi RAI in patients with differentiated thyroid cancer (DTC) who were in the low-risk group according to 2015 American Thyroid Associations Classification (ATA 2015) criteria. Between February 2016 and August 2018, 100 patients who received RAI treatment in our clinic after total thyroidectomy and who were in the low-risk group DTC were included in this retrospective study. These patients were divided into 2 groups: low-activity (30-50 mCi) (group 1) and high-activity (100 mCi) (group 2). While 54 patients were treated with low activity, 46 patients received high activity RAI. The 2 groups were compared according to the 1st- and 3rd-year treatment response status. According to the first-year follow-up, 15 patients were accepted as indeterminate response and 85 patients as excellent response. Three (5.5%) of the patients who were accepted as indeterminate response were in group 1 and 12 (26%) were in group 2. According to the third year follow-up, 1 patient in group 1 and 3 patients in group 2 were accepted as indeterminate response. No biochemical incomplete response or recurrent disease was detected. In the chi-square analysis performed to investigate the relationship between the first-year treatment response and RAI activities, a significant relationship was found (p=0.004). In the Mann-Whitney U test performed to investigate the parameters that may be effective in the treatment response, only the preablative serum thyroglobulin value was shown to have a significant difference between the two groups (p=0.01). In the long-term follow-up of the patients, based on the third year treatment response data, chi-square analysis was performed to evaluate the two groups in terms of treatment responses, and no statistically significant relationship was found (p=0.73). Ablation with 30-50 mCi can be safely applied in DTC patients who are in the ATA 2015 low-risk group and are planned for RAI ablation treatment.

Risk of Second Primary Malignancy Associated with Cumulative Doses of Radioactive Iodine in Patients with Differentiated Thyroid Cancer

Clinical ThyroidologyVol. 35, No. 4 Thyroid CancerRisk of Second Primary Malignancy Associated with Cumulative Doses of Radioactive Iodine in Patients with Differentiated Thyroid CancerDavid Toro-Tobon and Omar EI KawkgiDavid Toro-Tobon Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.Search for more papers by this author and Omar EI Kawkgi Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A. Department of Endocrinology, Mayo Clinic Health System, Eau Claire, Wisconsin, U.S.A.Search for more papers by this authorPublished Online:11 Apr 2023https://doi.org/10.1089/ct.2023;35.154-156AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 35Issue 4Apr 2023 Information© Copyright 2023, Mary Ann Liebert, Inc.To cite this article:David Toro-Tobon and Omar EI Kawkgi.Risk of Second Primary Malignancy Associated with Cumulative Doses of Radioactive Iodine in Patients with Differentiated Thyroid Cancer.Clinical Thyroidology.Apr 2023.154-156.http://doi.org/10.1089/ct.2023;35.154-156Published in Volume: 35 Issue 4: April 11, 2023PDF download

Current patterns of care in low-risk thyroid cancer-A national cross-sectional survey of Australian thyroid clinicians.

De-escalated treatment of hemithyroidectomy without radioactive iodine (RAI) is now accepted for patients with low-risk, well-differentiated thyroid cancer (WDTC). The benefit of long-term follow-up care remains controversial. This study aims to describe parameters associated with less than total thyroidectomy, and discharge from specialist follow-up in patients with low-risk WDTC in Australia. An online survey was distributed to Australian members of Endocrine Society of Australia, Australian and New Zealand Endocrine Surgeons, and Australian Society of Otolaryngology, Head and Neck Surgery. Clinicians completed a survey of management and follow-up care preferences for four clinical vignettes (all low-risk WDTC). 119 clinicians (48% endocrinologists, 55% male) answered at least one question. The majority (59%) of respondents recommended less than total thyroidectomy and omission of RAI in patients with WDTC <2 cm. Most (62%) would discharge a patient with micropapillary thyroid cancer within 1 year following total thyroidectomy. In contrast, for WDTC 1-4 cm, >90% of clinicians would continue specialist follow-up for at least 5 years. The majority of clinicians felt that patients experienced disproportionate fear of recurrence and were reassured by follow-up. After multivariable analysis, clinicians who participated in multidisciplinary teams (MDTs) were more likely to choose de-escalated care for both initial treatment (p = .005) and follow-up care (>5 years, p = .05). Clinician attitudes captured by this survey reflect recent changes in guidelines towards hemithyroidectomy for low-risk WDTC, particularly amongst MDT attendees. There is a need to further examine the impact of de-escalated care on fear of recurrence and quality of life in thyroid cancer survivors.

Greetings From the Editor of Clinical Thyroidology

Clinical ThyroidologyVol. 34, No. 6 Greetings from the EditorFree AccessGreetings From the Editor of Clinical ThyroidologyAngela M. LeungAngela M. LeungSearch for more papers by this authorPublished Online:13 Jun 2022https://doi.org/10.1089/ct.2022;34.235-236AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail DEAR COLLEAGUESWelcome to the June issue of Clinical Thyroidology. This issue begins with a review by Dr. Kenneth Burman, who summarizes a study on suboptimal thyroid hormone replacement. Drs. Ricardo Correa and Ricardo Villela discuss a study done in patients with subclinical hyperthyroidism and cardiovascular outcomes, while Drs. Eijun Nishihara and Takashi Akamizu review the findings of a recent trial of rituximab use in young patients with Graves’ disease.On the topic of thyroid nodules and thyroid cancer, Dr. Benjamin Gigliotti comments on a survey study summarizing respondents’ viewpoints of the various risk-stratification systems available for estimating malignancy risk. Drs. N. Rhea Udyavar and Lilah Morris-Wiseman review a study reporting the associations between thyroid autoimmunity and incident thyroid cancer, while Dr. Ulla Feldt-Rasmussen describes a Danish study assessing the relationships between education, socioecononomic status, and thyroid cancer incidence.The potential need for levothyroxine replacement in patients who undergo hemithyroidectomy for low-risk papillary thyroid cancer is always an interesting clinical question. Drs. Erivelto Volpi and Leonardo Volpi summarize a retrospective trial that studied this question. This issue also features a review by Drs. Anupam Kotwal and Whitney Goldner, who examine a recent study reporting the characteristics of patients with BRAF V600E–mutant papillary thyroid cancer. Drs. Sara Duffus and Lindsay Bischoff discuss a study assessing the differences between Hürthle-cell and follicular thyroid carcinomas. Finally, Dr. Mayumi Endo summarizes the findings of a phase 3 trial studying treatment with selumetinib and radioactive iodine in patients with high-risk differentiated thyroid cancer.Clinical Thyroidology will continue to feature select highlighted abstracts presented at the American Thyroid Association's 2021 annual meeting. In this issue, Drs. Tiba Abdulwahid and Karen Selk share their case report entitled “A Rare Hideaway.” I invite all our readers to learn about the interesting clinical course they describe.As always, we invite our readers to join us through our social media channels. Through these other ways of communication, we discuss content featured in each month's issue and other issues related to hot topics in the clinical thyroid literature:Twitter:https://twitter.com/clinicalthyroid(@clinicalthyroid)Facebook:https://www.facebook.com/ThyroidAssociationLinkedIn:https://www.linkedin.com/company/american-thyroid-associationYoutube:https://www.youtube.com/user/thyroidorgAlso note that most of the material covered in Clinical Thyroidology is also translated into shorter lay summaries in our sister journal, Clinical Thyroidology for the Public [CTFP] (https://www.thyroid.org/patient-thyroid-information/ct-for-patients), that is edited by Dr. Alan Farwell and his team each month. The summaries in CTFP may be of use to patients and the public who are interested in reading more about recently published studies in the clinical thyroid literature.I hope that each issue provides helpful reviews, commentaries, editorials, and perspectives regarding how best to treat patients with thyroid disease. Guidelines for submitting Letters to the Editor and select Guest Editorials that cover timely and innovative aspects of clinical thyroid disease management may be found at https://home.liebertpub.com/publications/clinical-thyroidologyand174/623/for-authors.Thank you again for your interest in Clinical Thyroidology. Please feel free to send me any questions or comments at clinicalthyroidology@thyroid.org.Warmest regards,Angela M. Leung, MD, MScEditor-in-Chief, Clinical ThyroidologyFiguresReferencesRelatedDetails Volume 34Issue 6Jun 2022 Information© Copyright 2022, Mary Ann Liebert, Inc.To cite this article:Angela M. Leung.Greetings From the Editor of Clinical Thyroidology.Clinical Thyroidology.Jun 2022.235-236.http://doi.org/10.1089/ct.2022;34.235-236Published in Volume: 34 Issue 6: June 13, 2022PDF download

Radioiodine-resistant metastases of well-differentiated thyroid cancer, analysis of tumor characteristics and primary surgical intervention

The aim of this article is to assess the initial status, characteristics of the tumor process and initial surgical treatment in patients with well-differentiated thyroid carcinomas who subsequently showed resistance to 131I therapy, comparing with the control group of patients who achieved a positive effect of 131I therapy. Materials and methods. In total, 156 cases of well-differentiated thyroid cancer were analyzed. The control group consisted of 189 patients who showed complete responses to treatment of metastases after 131I therapy and the confirmed relapse-free period. The patients were operated and followed up in the Department of Endocrine Gland Surgery of SI “V. P. Komisarenko Institute of Endocrinology and Metabolism of the National Academy of Medical Sciences of Ukraine” between 1990 and 2019. Results. Based on our study, in the group of radioiodine-resistant metastases, there was a 3.1:1.0 predominance of women over men; whereas in the control group, this ratio was 1.4:1.0. It was noted that resistance to radioactive iodine in patients under 20 years of age was 4 times significantly lower (10.26 %) comparing with the radiosensitive group (41.90 %). In the age group of 41–60 years, radioiodine resistance was 6.5 times higher than that in the comparison group (39.10 % and 6.35 %), and in the age group over 61 years – 11 times (11.54 % and 1.05 %). The impact analysis of radiation exposure on the radioiodine refractoriness occurrence revealed that among patients living in radiation-contaminated areas of Ukraine in 1986 following the Chornobyl accident, there were no significant differences in the development of resistance to radioactive iodine (resistance to 131I – 51.92 % (n = 81), treatment response 131I – 64.02 % (n = 121)). These differences may be due to the younger age of patients affected by radiation and better sensitivity to radioiodine compared to the main group patients. The maximum number of radioiodine-resistant observations was in the intermediate risk group (71.15 %; n = 111). Worth noting is the significant number of radioiodine-resistant metastases in the group where their absence was initially diagnosed (11.53 %; n = 18) and in the group where the proper assessment of lymph collectors was not performed (29.49 %; n = 46). Radioiodine resistance was significantly more common (33.97 %; n = 53) in observations where the prophylactic central dissection was not performed. Conclusions. The main risk factors in the development of radioiodine-resistant metastases were the age of patients older than 40 years, the limited primary surgery on regional lymphatic collectors of the neck, tumor aggressiveness. Careful pre- and intraoperative assessment of regional collectors of the lymph outflow, preventive central neck dissection and extensive therapeutic dissections can reduce the risk of residual and radioiodine-resistant metastases. Timely diagnosis of metastases can improve the results of primary surgical treatment for patients with differentiated thyroid carcinoma and reduce the incidence of radioiodine resistance.

Indication for radioactive iodine in patients with papillary thyroid carcinoma without apparent disease after total thyroidectomy but with elevated antithyroglobulin antibodies.

To evaluate a criterion for the selective indication of radioactive iodine (RAI) based on the short-term behaviour of antithyroglobulin antibodies (TgAb) in patients with papillary thyroid carcinoma (PTC) who have negative thyroglobulin (Tg) and neck ultrasonography (US) without abnormalities after total thyroidectomy but elevated TgAb. This was a prospective study that evaluated 216 patients with low- or intermediate-risk PTC who had nonstimulated Tg ≤ 0.2 ng/ml and no US abnormalities but elevated TgAb 3 months after thyroidectomy. RAI was not indicated in patients with negative TgAb or a >50% reduction in TgAb concentrations 6 months after initial assessment followed by a negative test or an additional reduction (also >50%) after 12 months. Only two of the 114 patients who did not receive RAI developed recurrences; another 108 patients met the criterion of an excellent response to therapy in the last assessment and TgAb persisted in four patients but there was an additional reduction in their concentration during follow-up. Among the 102 patients who received RAI, post-therapy whole-body scanning (RxWBS) detected persistent disease in 8 (8%). Two of the 94 patients without persistent disease on RxWBS developed recurrences. In the last assessment, in the absence of additional treatment, 54/92 patients (58.7%) without structural recurrence had negative TgAb. The indication for RAI can be based on the short-term behaviour of TgAb in patients with PTC and elevated TgAb after thyroidectomy who are not high risk and who do not have apparent disease (nonstimulated Tg ≤ 0.2 ng/ml and no US abnormalities).

A Patient With Graves’ Disease And Thyroid-Associated Orbitopathy Undergoing Radioactive Iodine in Dr. Soetomo General Academic Hospital, Surabaya

Graves’ Disease (GD) is the most common etiology of thyrotoxicosis, followed by toxic multinodular goiter and toxic adenoma. GD can be managed with anti-thyroid drugs (ATDs), surgery, or radioactive iodine (RAI). Thyroid-associated orbitopathy (TAO) or Graves’ Ophthalmopathy (GO) affects 25%-50% patients with GD, and its presence usually dissuade clinicians to use RAI in treating hyperthyroidism. The presence of GO is a relative contraindication use of RAI in patients with GD, as RAI can worsen existing GO. Corticosteroid prophylaxis can be given to such patients to reduce likelihood of worsening of GO. However, patient with moderate to severe active GO is currently advised against undergoing RAI. Established guidelines recommend the use of corticosteroid prophylaxis in these patients. We reported a patients with GD and orbitopathy who was treated with RAI and was given steroid prophylaxis to prevent worsening of GO.

Parathyroid Changes After RAI in Patients With Differentiated Thyroid Carcinoma.

ObjectiveThe purpose of this study was to investigate parathyroid hormone (PTH), serum calcium, phosphorus, and 25-hydroxyvitamin D (25-OH-VD) changes before and after radioactive iodine (RAI) in differentiated thyroid carcinoma (DTC) patients at different time points.MethodsA total of 259 DTC patients who received RAI were prospectively enrolled. We evaluated PTH, serum calcium, phosphorus, and 25-OH-VD levels at baseline pre-RAI, five days, six weeks, and six months post-RAI, respectively. We analyzed the risk factors of hypocalcemia at five days post-RAI.ResultsThe mean PTH, serum calcium and phosphorus values decreased five days post-RAI compared with pre-RAI (PTH 4.18 ± 1.23 pmol/L vs. 3.95 ± 1.41 pmol/L; calcium 2.27 ± 0.09 mmol/L vs. 2.20 ± 0.11 mmol/L; phosphorus 1.25 ± 0.17 vs. 0.98 ± 0.20 mmol/L, P < 0.05), and the differences were statistically significant. The mean 25-OH-VD levels did not significantly decrease at five days post-RAI. 21.2% (55/259) of patients had hypocalcemia at five days post-RAI, and all of them were given oral calcium supplements. At six weeks post-RAI, all of the above parameters were higher than those at five days post-RAI. Multivariate regression analysis showed that baseline pre-RAI serum calcium < 2.27 mmol/L, PTH < 4.18 pmol/L and negative 99mTcO4 - thyroid imaging were risk factors for hypocalcemia at five days post-RAI.ConclusionFor DTC patients with normal PTH and serum calcium levels at pre-RAI, their PTH, serum calcium, and phosphorus levels decreased at five days post-RAI. About one-fifth of patients could have hypocalcemia at five days post-RAI. Lower baseline pre-RAI serum calcium and PTH levels and negative 99mTcO4 - thyroid imaging were risk factors for hypocalcemia five days post-RAI.

Role of adjuvant therapy with radioactive iodine in patients with elevated serum thyroglobulin after neck reoperation due to recurrent papillary thyroid cancer: a monoinstitutional comparative study.

Most patients with papillary thyroid cancer (PTC) and lymph node metastases (LNM) undergoing reoperation do not show apparent disease after this procedure, but serum thyroglobulin (Tg) continues to be elevated in part of them. This study evaluated adjuvant therapy with 131I in these patients. Patients with PTC and LNM diagnosed after initial therapy were selected. Patients undergoing reoperation and those without apparent disease after this procedure, but with nonstimulated Tg ≥1 ng/ml 6 months after reoperation, were included. The first 25 patients were submitted to therapy with 131I (groups A) and the subsequent 30 patients did not receive this therapy (group B). Groups A and B were similar. During further follow-up, 21 patients developed structural disease and 34 continued without detectable disease (eight achieved complete remission). The outcomes were similar in groups A and B. Patients with Tg reduction >50% after reoperation tended to have a lower risk of recurrence (22.7 versus 48.5%), notably distant metastases (0 versus 15.1%), and were more likely to achieve complete remission (28 versus 3%). Patients with LNM FDG-positive had a higher risk of recurrence (54.5 versus 11.7%) and were less likely to achieve complete remission (3 versus 29.4%) after reoperation. Our results suggest that therapy with 131I apparently does not prevent recurrences among patients who continue to have elevated Tg after neck reoperation. Further studies involving these patients are necessary, especially those who are at high risk of recurrence.

Early Postoperative Unstimulated Serum Thyroglobulin Predicts Utility of Radioactive Iodine in Patients with Papillary Thyroid Cancer

Early Postoperative Unstimulated Serum Thyroglobulin Predicts Utility of Radioactive Iodine in Patients with Papillary Thyroid Cancer

Radioactive iodine in differentiated thyroid cancer: a national database perspective.

Radioactive iodine (RAI) is a key component in the treatment of differentiated thyroid cancer. RAI has been recommended more selectively in recent years as guidelines evolve to reflect risks and utility in certain patient subsets. In this study we sought to evaluate the survival impact of radioactive iodine in specific thyroid cancer subgroups. Nationwide retrospective cohort study of patients using the National Cancer Database (NCDB) from 2004 to 2012 and Surveillance, Epidemiology, and End Results (SEER) database from 1992 to 2009 examining patients with differentiated thyroid cancer treated with or without RAI. Primary outcomes included all-cause mortality (NCDB and SEER), and cancer-specific mortality (SEER). Cox multivariate survival analyses were applied to each dataset, and in 135 patient subgroups based on clinical and non-clinical parameters. A total of 199,371 NCDB and 77,187 SEER patients were identified. RAI was associated with improved all-cause mortality (NCDB: RAI hazard ratio (HR) 0.55, P < 0.001; SEER: HR 0.64, P < 0.001); and cancer-specific mortality (SEER: HR 0.82, P = 0.029). Iodine therapy showed varied efficacy within each subgroup. Patients with high-risk disease experienced the greatest benefit in all-cause mortality, followed by intermediate-risk, then low-risk subgroups. Regarding cancer-specific mortality, radioactive iodine therapy was protective in high-risk patients, but did not achieve statistical significance in most intermediate-risk subgroups. Low-risk T1a subgroups demonstrated an increased likelihood of cancer-specific mortality with iodine therapy. The efficacy of RAI in patients with differentiated thyroid cancer varies by disease severity. A negative cancer-specific survival association was identified in patients with T1a disease. These findings warrant further evaluation with prospective studies.

Low-Activity Radioactive Iodine Therapy for Thyroid Carcinomas Exhibiting Nodal Metastases and Extrathyroidal Extension May Lead to Early Disease Recurrence.

The application of radioactive iodine in differentiated thyroid carcinomas has become more selective in an attempt to decrease morbidity. While ablative success has been documented, it is less clear how changes in radioactive iodine treatment strategies will influence long-term recurrence rates for patients with larger tumors and adverse pathological features, including extrathyroidal extension and nodal metastases. Patients diagnosed between 1995 and 2008 with differentiated thyroid carcinoma treated with thyroidectomy followed by radioactive iodine treatment were eligible. All patients were followed for a minimum of five years using a standardized follow-up protocol requiring both biochemical and imaging assessments for recurrent disease (n = 219). Patients were stratified by initial radioactive iodine activity, and disease-free survival was calculated using the Kaplan-Meier method, with significant differences defined by the log-rank test. In this cohort, 46% of patients had clinical metastases and 74% had primary tumors >1.5 cm. Patients who had recurrences were more likely to present with extrathyroidal extension (p = 0.002) and lymph node metastases at diagnosis (p < 0.001). Patients presenting with both extrathyroidal extension and lymph node metastases had a significantly worse time to progression if treated with <1850 MBq radioactive iodine compared to those patients treated with >1850 MBq (25 months vs. 121 months; p = 0.004). The use of lower-activity radioactive iodine ablative therapy was associated with more early recurrences (p = 0.003). Being aged younger or older than 45 years did not impact the time to recurrence nor did the use of level 6 dissection. On multivariate analysis, lymph node metastases at diagnosis and multiple applications of radioactive iodine were linked to increased risk of recurrence. Patients with neither, or only one, adverse pathologic feature had excellent outcomes, regardless of initial ablative activity, with <10% of patients recurring over a 10-year time span. Recurrent disease in differentiated thyroid carcinoma is more common in patients treated with low-activity radioactive iodine in patients with lymph node metastases and extrathyroidal extension. These recurrences typically occur within four years of initial treatment. Patients lacking both of these risk factors treated with low radioactive iodine activity (<1850 MBq) have excellent outcomes, even after 10 years.

EVALUATION OF DRUG THERAPY IN PROGRESSING DIFFERENTIATED THYROID CANCER REFRACTORY TO RADIOACTIVE IODINE IN PATIENTS RESIDING IN THE RUSSIAN FEDERATION : PHARMACOECONOMIC ASPECTS

The aim of this study was to identify the most effective (in the clinical and pharmacoeconomic aspects) drug for the treatment of widespread progressing differentiated thyroid cancer (DTC) refractory to radioactive iodine in patients – residents of the Russian Federation. Materials and Methods . The budget impact and the “cost-effectiveness” parameters were analyzed using the MS Excel-model based on a 3-year period. The “cost-effectiveness” analysis was performed to compare the use of lenvatinib 15.28 mg/day, sorafenib 651 mg/day (after dose reduction), and chemotherapeutic agents. As part of the budget impact analysis (BIA), two scenarios were simulated: 1. DTC treatment using sorafenib and the chemotherapeutic agents (CTA);2. In some patients, the sorafenib + CTA therapy has been replaced with lenvatinib. The only parameter analyzed in this model was the drug cost. In the BIA, the impact of scenario 2 on the entire budget reserved for the thyroid cancer treatment was evaluated. Results . Lenvatinib proved an effective agent (with a manageable safety profile) to be used in monotherapy of DTC refractory to radioactive iodine. According to the BIA, the introduction of lenvatinib had virtually no effect on the cost of thyroid cancer treatment. Using the “progression free survival” parameter, the cost-effectiveness ratio (CER) showed that the annual cost of effective treatment of DTC refractive to radioactive iodine with sorafenib or lenvatinib was 7 285 716.92 rubles or 3 368 077.62 rubles, respectively.

Failure of radioactive iodine in the treatment of hyperthyroidism.

Persistent or recurrent hyperthyroidism after treatment with radioactive iodine (RAI) is common and many patients require either additional doses or surgery before they are cured. The purpose of this study was to identify patterns and predictors of failure of RAI in patients with hyperthyroidism. We conducted a retrospective review of patients treated with RAI from 2007 to 2010. Failure of RAI was defined as receipt of additional dose(s) and/or total thyroidectomy. Using a Cox proportional hazards model, we conducted univariate analysis to identify factors associated with failure of RAI. A final multivariate model was then constructed with significant (p < 0.05) variables from the univariate analysis. Of the 325 patients analyzed, 74 patients (22.8 %) failed initial RAI treatment, 53 (71.6 %) received additional RAI, 13 (17.6 %) received additional RAI followed by surgery, and the remaining 8 (10.8 %) were cured after thyroidectomy. The percentage of patients who failed decreased in a stepwise fashion as RAI dose increased. Similarly, the incidence of failure increased as the presenting T3 level increased. Sensitivity analysis revealed that RAI doses <12.5 mCi were associated with failure while initial T3 and free T4 levels of at least 4.5 pg/mL and 2.3 ng/dL, respectively, were associated with failure. In the final multivariate analysis, higher T4 (hazard ratio [HR] 1.13; 95 % confidence interval [CI] 1.02-1.26; p = 0.02) and methimazole treatment (HR 2.55; 95 % CI 1.22-5.33; p = 0.01) were associated with failure. Laboratory values at presentation can predict which patients with hyperthyroidism are at risk for failing RAI treatment. Higher doses of RAI or surgical referral may prevent the need for repeat RAI in selected patients.

Factors associated with receipt of adjuvant radioactive iodine in node-negative versus node-positive papillary thyroid cancer.

e17695 Background: The administration of adjuvant radioactive iodine (RAI) for patients with papillary thyroid cancer (PTC) is controversial. Current guidelines recommend RAI for patients at high r...

Prophylactic Central Neck Dissection Increases the Cost of Thyroid Cancer Care

Over the past several decades, health care spending has risen faster than any other segment of the United States economy and continues to rise. Media attention has been focused on health care costs since the introduction of the Patient Protection and Affordable Care Act of 2010, which aims to reduce costs of health care while improving outcomes. Physicians are in the best position to determine which treatments are effective and which patients benefit most, and they are more cognizant than ever of the mandate to spend our limited health care dollars wisely. Cost minimization should be the goal of every physician, as long as quality of care does not diminish. The incidence of papillary thyroid cancer (PTC) is increasing in the United States, but thankfully survival is excellent compared with many other cancers. Patients diagnosed when the disease is limited to the thyroid gland are nearly always cured with thyroidectomy. Unfortunately, regional lymph node metastases from PTC are very common, with the majority of patients having at least micrometastatic disease in the central neck at the time of diagnosis. Nodal involvement increases the risk of recurrence, which plays an important role in the long-term management of this disease. While there is no debate about removing clinically apparent lymph node disease at the initial surgery, there is significant debate regarding the utility of performing a prophylactic central lymph node dissection (pCND) as part of the initial thyroidectomy when there is no evidence of lymph node involvement. There has not been a definitive randomized controlled trial to date, and there are strong advocates on both sides of the argument. Proponents claim pCND saves future morbidity of repeat operations without adding much operative risk to the initial operation, while opponents feel it adds operative morbidity without altering long-term outcomes for the majority of patients. Most of the available literature has struggled to address either the risk or the benefit of pCND, and there has been no consensus. Lang et al., in this current issue, aim to answer the question from a costeffectiveness perspective, adding yet another dimension to this debate at a timely moment in national discourse. They report, unsurprisingly, that the initial procedural costs are higher for pCND at the time of initial surgery for node-negative PTC versus performing a simple thyroidectomy alone. The key question is whether that initial investment (and higher costs of more initial complications) saves health care spending in the long term by reducing the rates of reoperations and future complications. Using data from their recent well-done meta-analysis of 14 studies with 3,331 patients, the authors used odds ratios for complications of both initial surgeries, recurrence rates, and the likelihood of radioactive iodine (RAI) treatment to create a mathematical model. This model projected out costs for a hypothetical cohort of 100,000 women with a 1.5-cm papillary thyroid cancer. Using it, they found that pCND is not cost saving and calculated that, over 20 years, the accumulated direct costs of a thyroidectomy with pCND is $3000 more than initially performing a thyroidectomy alone and dealing with recurrences as they arise. In this hypothetical cohort of patients, the higher costs of pCND are mostly attributable to (1) longer operative time and greater complexity of the operation, (2) more initial complications, and (3) higher percentage of postoperative RAI in patients with pCND. Reoperations actually have similar costs in this model, and while fewer This is an editorial to the article available at doi: 10.1245/s10434013-3234-9.

The Relationship Between Extent of Thyroid Cancer Surgery and Use of Radioactive Iodine

By linking surgeon surveys to the National Cancer Database, we found that surgeons' tendency to perform more extensive thyroid resection is associated with greater use of radioactive iodine for stage I thyroid cancer. To determine the relationships between surgeon recommendations for extent of resection and radioactive iodine use in low-risk thyroid cancer. There has been an increase in thyroid cancer treatment intensity; the relationship between extent of resection and medical treatment with radioactive iodine remains unknown. We randomly surveyed thyroid surgeons affiliated with 368 hospitals with Commission on Cancer-accredited cancer programs. Survey responses were linked to the National Cancer Database. The relationship between extent of resection and the proportion of the American Joint Committee on Cancer stage I well-differentiated thyroid cancer patients treated with radioactive iodine after total thyroidectomy was assessed with multivariable weighted regression, controlling for hospital and surgeon characteristics. The survey response rate was 70% (560/804). Surgeons who recommend total thyroidectomy over lobectomy for subcentimeter unifocal thyroid cancer were significantly more likely to recommend prophylactic central lymph node dissection for thyroid cancer regardless of tumor size (P < 0.001). They were also more likely to favor radioactive iodine in patients with intrathyroidal unifocal cancer ≤1 cm (P = 0.001), 1.1-2 cm (P = 0.004), as well as intrathyroidal multifocal cancer ≤1 cm (P = 0.004). In multivariable analysis, high hospital case volume, fewer surgeon years of experience, general surgery specialty, and preference for more extensive resection were independently associated with greater hospital-level use of radioactive iodine for stage I disease. In addition to surgeon experience and specialty, surgeons' tendency to perform more extensive thyroid resection is associated with greater use of radioactive iodine for stage I thyroid cancer.

The role of long term use of antithyroid drugs in Graves’ disease

Graves' disease is an autoimmune disease characterized by hyperthyroidism due to circulating autoantibodies. Radioactive iodine (RAI) and antithyroid drugs (ATD) are the preferred initial treatment options in Graves' disease in many parts of the world. Long term treatment with methimazole in Grave's disease patients beyond the recommended period is shown to be safe and effective and emerging evidence suggests that continuous methimazole therapy may even be superior to RAI therapy in some aspects. Recent randomized trials comparing long-term methimazole to RAI in patients who relapse, have confirmed these findings Sri Lanka Journal of Diabetes, Endocrinology and Metabolism 2013; 3 : 41-44 DOI: http://dx.doi.org/10.4038/sjdem.v3i1.5503

Salivary and Lacrimal Gland Dysfunction After Remnant Ablation with Radioactive Iodine in Patients with Differentiated Thyroid Carcinoma Prepared with Recombinant Human Thyrotropin

One of the adverse effects of radioactive iodine (¹³¹I) treatment in patients with thyroid cancer is damage to the salivary and lacrimal glands. In almost all studies evaluating salivary and lacrimal gland dysfunction, the patients received ¹³¹I after levothyroxine (L-T4) withdrawal. Since the biokinetics of ¹³¹I after recombinant human thyrotropin (rhTSH) is not the same as in hypothyroidism, studies need to evaluate ¹³¹I-induced salivary and lacrimal toxicity after preparation with rhTSH. This prospective study investigated the occurrence of salivary and lacrimal damage after ablation with ¹³¹I using this preparation. One hundred forty-eight patients who had a total thyroidectomy were included in the study. The subjects were evaluated after thyroidectomy during L-T4 use to exclude those who already showed symptoms or had a history of ocular or oral disease. Symptoms were investigated 12 and 18 months after ablation. In patients who had persistent symptoms, specific tests were performed to confirm glandular dysfunction and to rule out other causes. Twelve months after ablation, symptoms of salivary or lacrimal dysfunction were observed in 10 (6.7%) patients, including oral symptoms in 8 (5.4%) and ocular symptoms in 6 (4%). Eighteen months after ¹³¹I, symptoms persisted in eight (5.4%) patients, including oral symptoms in seven (4.7%) and ocular symptoms in five (3.4%). In all of the patients, glandular dysfunction was confirmed by specific tests and other causes were ruled out. No symptoms were seen in the patients who received a low ¹³¹I dose (30 mCi). In the patients who received high ¹³¹I doses (100 or 150 mCi), symptoms were noted 12 months after ¹³¹I in 10 patients (9.2%), and 18 months after ¹³¹I in 8 patients (7.4%). Apparently, the rates of salivary and lacrimal damage were lower than those reported in prospective studies that used similar ¹³¹I activities, but these studies were performed in patients who were hypothyroid at the time of ¹³¹I ablation. Further studies are needed to compare radiotoxicity between patients prepared for ¹³¹I ablation with rhTSH and those prepared for ¹³¹I ablation with L-T4 withdrawal.