Thyroid nodule medical therapy: Difference between revisions

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==Overview==
==Overview==
In case of active hot thyroid nodules that produce [[thyroid hormones]], [[Antithyroid agent|antithyroid drugs]] should be administered, that include [[beta-blockers]], antithyroid drugs ([[methimazole]],[[carbimazole]],[[propylthiouracil]]), [[Iodine-131|radioactive iodine]], and [[thyroidectomy]]. If the nodule excision treatment ([[lobectomy]], [[isthmectomy]], and total [[thyroidectomy]]) is not curative, then treatment with postoperative [[radioactive iodine]] ([[RAI1|RAI]]) remnant ablation and recombinant human TSH–mediated therapy is recommended.


==Medical Therapy==
==Medical Therapy ==
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In case of active hot thyroid nodule that produce thyroid hormones, antithyroid drugs should be administered. The table below summarize the treatment options in case of thyroid nodules presence:
In case of active hot thyroid nodule that produce [[thyroid hormones]], [[Antithyroid agent|antithyroid drugs]] should be administered. The table below summarizes the treatment options in case of hot thyroid nodules:
{| class="wikitable"
{| class="wikitable"
!Treatment
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Treatment
!Mechanism
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Mechanism
!Route of administration
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Route of administration
!Advantages
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Advantages
!Disadvantages
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Disadvantages
!Special considerations
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Special considerations
|-
|-
!Beta-blockers
![[Beta-blockers]]
|
|
* Block β-adrenergic receptors;
* [[Beta adrenergic blockade|Block β-adrenergic receptors]]


* Propranolol may block conversion of T4 to T3
* [[Propranolol]] may block conversion of [[T4]] to [[T3]]
|Oral
|Oral
|
|
* Ameliorates sweating, anxiety, tremulousness, palpitations, and tachycardia
* Ameliorates [[sweating]], [[anxiety]], tremulousness, [[palpitations]], and [[tachycardia]]
|
|
* Does not influence course of disease
* Does not influence course of disease


* Administer just in case of hot thyroid nodule with thyrotoxicosis manifestations
* Administer just in case of hot thyroid nodule with [[thyrotoxicosis]] manifestations
* Use cautiously in patients with asthma, CHF , bradyarrhythmias or Raynaud’s phenomenon  
* Use cautiously in patients with [[asthma]], [[CHF]] , [[bradyarrhythmias]] or [[Raynaud’s phenomenon]]
|
|
* Use cardioselective beta-blockers, especially in patients with COPD  
* Use [[Beta-blockers|cardioselective beta-blockers]], especially in patients with [[COPD]]
* Use calcium-channel blockers as alternative
* Use [[calcium-channel blockers]] as an alternative
|-
|-
! Antithyroid drugs ([[methimazole]],
! Antithyroid drugs ([[methimazole]],
[[carbimazole]],[[propylthiouracil]])
[[carbimazole]],[[propylthiouracil]])
|
|
* Methimazole, carbimazole, and propylthiouracil block thyroid peroxidase and thyroid hormone synthesis  
* [[Methimazole]], [[carbimazole]], and [[propylthiouracil]] block [[thyroid peroxidase]] and [[Thyroid hormone|thyroid hormone synthesis]]


* Propylthiouracil also blocks conversion of thyroxine to triiodothyronine
* [[Propylthiouracil]] also blocks conversion of [[thyroxine]] to [[triiodothyronine]]
|Given as either a single, high fixed dose (e.g., 10–30 mg of methimazole or 200–600 mg of propylthiouracil daily)
|Given as either a single, high fixed dose (e.g., 10–30 mg of [[methimazole]] or 200–600 mg of [[propylthiouracil]] daily)


and adjusted as euthyroidism is achieved or combined with thyroxine to prevent hypothyroidism (“block–replace” regimen)
and adjusted as euthyroidism is achieved or combined with [[thyroxine]] to prevent [[hypothyroidism]] (“block–replace” regimen)
|
|
* Outpatient therapy
* Outpatient therapy
* Low risk of hypothyroidism
* Low risk of [[hypothyroidism]]
* No radiation hazard or surgical risk
* No radiation hazard or surgical risk
|
|
* Frequent testing required unless block-replacement therapy is used
* Frequent testing required unless block-replacement therapy is used
* Minor side effects in ≤5% of patients (rash, urticaria, arthralgia, fever, nausea, abnormalities of taste and smell)
* Minor side effects in ≤5% of patients ([[rash]], [[urticaria]], [[arthralgia]], [[fever]], [[nausea]], abnormalities of taste and smell)
| Major side effect usually within first 3 months of therapy
| Major side effects usually occur within first 3 months of therapy:
* Agranulocytosis in <0.2% of patients
* [[Agranulocytosis]] in <0.2% of patients
* Hepatotoxicity in ≤0.1%
* [[Hepatotoxicity]] in ≤0.1%
* Cholestasis for the thionamides and hepatocellular necrosis for propylthiouracil
* [[Cholestasis]] for the thionamides and hepatocellular [[necrosis]] for [[propylthiouracil]]
* Antineutrophil cytoplasmic antibody–associated vasculitis in ≤0.1% of patients
* [[Anti-neutrophil cytoplasmic antibody|Antineutrophil cytoplasmic antibody]]–associated [[vasculitis]] in ≤0.1% of patients
|-
|-
![[Iodine-131|Radioactive iodine]]
![[Iodine-131|Radioactive iodine]]
Line 72: Line 73:
(iodine-131)
(iodine-131)
|
|
* Irradiation causes thyroid cell damage and cell death
* [[Irradiation]] causes [[thyroid]] [[Cell (biology)|cell]] damage and [[Cell (biology)|cell]] death
| Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations
| Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of [[goiter]] size and uptake and turnover investigations
|
|
* Normally outpatient procedure
* Normally outpatient procedure
Line 81: Line 82:
* Effectively reduces nodule size
* Effectively reduces nodule size
|
|
* Potential radiation hazards
* Potential [[radiation]] hazards
* Adherence to a country’s particular radiation regulations  
* Adherence to a country’s particular [[radiation]] regulations  
* Radiation thyroiditis
* [[Radiation]] thyroiditis
* Eventually destroy thyroid completely and lead to hypothyroidism in most patients
* Eventually destroys thyroid completely and leads to [[hypothyroidism]] in most patients
|
|
* Should not be used in patients with active thyroid ophthalmopathy
* Should not be used in patients with active [[Thyroid opthalmopathy|thyroid ophthalmopathy]]
* Contraindicated in women who are pregnant or breast-feeding and for 6 wk after breast-feeding has stopped
* Contraindicated in women who are [[pregnant]] or [[breast-feeding]] and for 6 weeks after [[breast-feeding]] has stopped
|-
|-
! Thyroidectomy
! [[Thyroidectomy]]
|
|
* Most or all thyroid tissue is removed surgically
* Most or all thyroid tissue is removed surgically
| -----
| -----
|
|
* Recurrence may happen in the case of metastasis and high stages of the cancer
* Recurrence may happen in the case of [[metastasis]] and high stages of the cancer
* No radiation hazard
* No [[radiation]] hazard
* Definitive histologic results
* Definitive [[histologic]] results
* Rapid relief of pressure symptoms
* Rapid relief of pressure symptoms
|
|
* Most expensive therapy
* Most expensive therapy
* Hypothyroidism is the aim
* [[Hypothyroidism]] is the aim
* Risks associated with surgery and anesthesiology  
* Risks associated with surgery and [[anesthesiology]]
* Minor complications in 1–2% of patients (bleeding, infection, scarring)
* Minor complications in 1–2% of patients ([[bleeding]], [[infection]], [[scarring]])
* Major complications in 1–4% (hypoparathyroidism, recurrent laryngeal-nerve damage)
* Major complications in 1–4% ([[hypoparathyroidism]], [[Recurrent laryngeal nerve|recurrent laryngeal-nerve]] damage)
|
|
* Should just be performed in patients with high suspicious toward malignancy
* Should just be performed in patients with high suspicion towards [[malignancy]]
|}
|}


Medical therapy goals in thyroid malignancies and differentiated thyroid cancers (DTC) include:
Medical therapy goals in [[Thyroid malignancy|thyroid malignancies]] and differentiated thyroid cancers (DTC) include:
* To remove:
* To remove:
** To remove primary tumor
** To remove [[primary tumor]]
** To eliminate the disease that has extended beyond the thyroid capsule
** To eliminate the disease that has extended beyond the [[thyroid]] capsule
** To remove involved cervical lymph nodes
** To remove involved [[cervical lymph nodes]]
** To minimize treatment-related morbidity  
** To minimize treatment-related [[morbidity]]
** To permit accurate staging of the disease  
** To permit accurate staging of the disease  
** To facilitate postoperative treatment with radioactive iodine, where appropriate  
** To facilitate postoperative treatment with [[radioactive iodine]] where appropriate  
** To permit accurate long-term surveillance for disease recurrence
** To permit accurate long-term surveillance for disease recurrence
** To minimize the risk of disease recurrence and metastatic spread
** To minimize the risk of disease recurrence and metastatic spread
A complete surgical resection of involved lymph nodes is one of the most important determinants of prognosis. Presence of lymph node involvement after the resection surgery represent a metastatic disease. The primary tumor in this case is mainly in the site of involved lymph node.<ref name="pmid14732779">{{cite journal |vauthors=Wang TS, Dubner S, Sznyter LA, Heller KS |title=Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes |journal=Arch. Otolaryngol. Head Neck Surg. |volume=130 |issue=1 |pages=110–3 |year=2004 |pmid=14732779 |doi=10.1001/archotol.130.1.110 |url=}}</ref><ref name="pmid8256208">{{cite journal |vauthors=Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS |title=Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989 |journal=Surgery |volume=114 |issue=6 |pages=1050–7; discussion 1057–8 |year=1993 |pmid=8256208 |doi= |url=}}</ref><ref name="pmid21113383">{{cite journal |vauthors=Ito Y, Miyauchi A |title=Thyroidectomy and lymph node dissection in papillary thyroid carcinoma |journal=J Thyroid Res |volume=2011 |issue= |pages=634170 |year=2010 |pmid=21113383 |pmc=2989453 |doi=10.4061/2011/634170 |url=}}</ref>


Both RAI whole-body scanning (WBS) and measurement of serum Tg are affected by residual normal thyroid tissue. Where these approaches are utilized for long-term monitoring, near-total or totalthyroidectomy is required<ref name="pmid10365671">{{cite journal |vauthors=Mazzaferri EL |title=An overview of the management of papillary and follicular thyroid carcinoma |journal=Thyroid |volume=9 |issue=5 |pages=421–7 |year=1999 |pmid=10365671 |doi=10.1089/thy.1999.9.421 |url=}}</ref>
* A complete surgical resection of involved [[lymph nodes]] is one of the most important determinants of [[prognosis]]. Presence of [[lymph node]] involvement after the resection surgery represent a [[metastatic disease]]. The [[primary tumor]] in this case is mainly in the site of involved [[lymph node]].<ref name="pmid14732779">{{cite journal |vauthors=Wang TS, Dubner S, Sznyter LA, Heller KS |title=Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes |journal=Arch. Otolaryngol. Head Neck Surg. |volume=130 |issue=1 |pages=110–3 |year=2004 |pmid=14732779 |doi=10.1001/archotol.130.1.110 |url=}}</ref><ref name="pmid8256208">{{cite journal |vauthors=Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS |title=Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989 |journal=Surgery |volume=114 |issue=6 |pages=1050–7; discussion 1057–8 |year=1993 |pmid=8256208 |doi= |url=}}</ref><ref name="pmid21113383">{{cite journal |vauthors=Ito Y, Miyauchi A |title=Thyroidectomy and lymph node dissection in papillary thyroid carcinoma |journal=J Thyroid Res |volume=2011 |issue= |pages=634170 |year=2010 |pmid=21113383 |pmc=2989453 |doi=10.4061/2011/634170 |url=}}</ref>
 
* Both [[Radioactive iodine uptake|RAI]] whole-body scanning (WBS) and measurement of serum [[thyroglobulin]] are affected by residual normal [[Thyroid|thyroid tissue]]. Where these approaches are utilized for long-term monitoring, near-total or total [[thyroidectomy]] is required.<ref name="pmid10365671">{{cite journal |vauthors=Mazzaferri EL |title=An overview of the management of papillary and follicular thyroid carcinoma |journal=Thyroid |volume=9 |issue=5 |pages=421–7 |year=1999 |pmid=10365671 |doi=10.1089/thy.1999.9.421 |url=}}</ref>
 
* Adequate surgery is the most important treatment variable influencing [[prognosis]], while [[radioactive iodine]] treatment, [[TSH]] suppression, and [[External beam radiotherapy|external beam irradiation]] each play adjunctive roles in at least some patients.<ref name="pmid12605980">{{cite journal |vauthors=Kim TH, Yang DS, Jung KY, Kim CY, Choi MS |title=Value of external irradiation for locally advanced papillary thyroid cancer |journal=Int. J. Radiat. Oncol. Biol. Phys. |volume=55 |issue=4 |pages=1006–12 |year=2003 |pmid=12605980 |doi= |url=}}</ref>
 
* There is a high risk of complication in thyroid nodule surgery. The most important factors determining surgical complications are:<ref name="pmid9742915">{{cite journal |vauthors=Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R |title=The importance of surgeon experience for clinical and economic outcomes from thyroidectomy |journal=Ann. Surg. |volume=228 |issue=3 |pages=320–30 |year=1998 |pmid=9742915 |pmc=1191485 |doi= |url=}}</ref>
** The extent of [[surgery]]
** The experience of the surgeon


Adequate surgery is the most important treatment variable influencing prognosis, while radioactive iodine treatment, TSH suppression, and external beam irradiation each play adjunctive roles in at least some patients<ref name="pmid12605980">{{cite journal |vauthors=Kim TH, Yang DS, Jung KY, Kim CY, Choi MS |title=Value of external irradiation for locally advanced papillary thyroid cancer |journal=Int. J. Radiat. Oncol. Biol. Phys. |volume=55 |issue=4 |pages=1006–12 |year=2003 |pmid=12605980 |doi= |url=}}</ref>
* Removal of all [[Thyroid|thyroid tissue]] (both normal and nodular) in patients undergoing [[radioactive iodine]] remnant ablation or [[radioactive iodine]] treatment of residual or [[metastatic disease]], is an important element of initial surgery. It has been recommended to perform a near total or total [[thyroidectomy]], as evidences show it may reduce the risk for [[neoplasia]] recurrence within the contralateral lobe. <ref name="pmid9499265">{{cite journal |vauthors=Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY |title=Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation |journal=Am. J. Clin. Oncol. |volume=21 |issue=1 |pages=77–81 |year=1998 |pmid=9499265 |doi= |url=}}</ref><ref name="pmid11742318">{{cite journal |vauthors=Esnaola NF, Cantor SB, Sherman SI, Lee JE, Evans DB |title=Optimal treatment strategy in patients with papillary thyroid cancer: a decision analysis |journal=Surgery |volume=130 |issue=6 |pages=921–30 |year=2001 |pmid=11742318 |doi=10.1067/msy.2001.118370 |url=}}</ref>


There is a high risk of complication in thyroid nodule surgery. The most important factors determining surgical complications are:<ref name="pmid9742915">{{cite journal |vauthors=Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R |title=The importance of surgeon experience for clinical and economic outcomes from thyroidectomy |journal=Ann. Surg. |volume=228 |issue=3 |pages=320–30 |year=1998 |pmid=9742915 |pmc=1191485 |doi= |url=}}</ref>
* Some experts recommend [[thyroid hormone]] administration in the case of benign thyroid nodule in iodine insufficient areas as a treatment. [[Thyroid hormone]] administration in larger than needed doses that decrease the [[serum]] [[TSH]] to subnormal levels, may lead to a decrease in nodule size and may be beneficial in regions of the world with borderline low [[iodine]] intake, as it may prevent new nodule formation. However, in [[iodine]] sufficient areas, there are insufficient evidences that administrating [[thyroid hormone]] may have a beneficial effect on benign thyroid nodules.
* The extent of surgery
* The experience of the surgeon
Removal of all thyroid tissue (both normal and nodular) in patients undergoing radioactive iodine remnant ablation or radioactive iodine treatment of residual or metastatic disease, is an important element of initial surgery. It has been recommended to perform a near total or total thyroidectomy, as evidences show it may reduce the risk for neoplasia recurrence within the contralateral lobe. <ref name="pmid9499265">{{cite journal |vauthors=Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY |title=Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation |journal=Am. J. Clin. Oncol. |volume=21 |issue=1 |pages=77–81 |year=1998 |pmid=9499265 |doi= |url=}}</ref><ref name="pmid11742318">{{cite journal |vauthors=Esnaola NF, Cantor SB, Sherman SI, Lee JE, Evans DB |title=Optimal treatment strategy in patients with papillary thyroid cancer: a decision analysis |journal=Surgery |volume=130 |issue=6 |pages=921–30 |year=2001 |pmid=11742318 |doi=10.1067/msy.2001.118370 |url=}}</ref>


Some experts recommend thyroid hormone administration in the case of benign thyroid nodule in iodine insufficient areas as a treatment. Thyroid hormone administration in larger than needed doses that decrease the serum TSH to subnormal levels, may lead to a decrease in nodule size and may be beneficial in regions of the world with borderline low iodine intake, as it may prevent new nodule formation. However, in iodine sufficient areas, there are insufficient evidences that administrating thyroid hormone may have a beneficial effect on benign thyroid nodules.
* If findings of [[FNA]] is suspicious for or diagnostic of [[Papillary thyroid cancer|papillary thyroid carcinoma]] in a pregnant woman, [[Levothyroxine|levothyroxin (T4)]] therapy should be considered as a primary therapy in order to keep the [[TSH]] in the normal range to avoid [[thyroid]] related problems in newborn.<ref name="pmid19451480">{{cite journal |vauthors=Kuy S, Roman SA, Desai R, Sosa JA |title=Outcomes following thyroid and parathyroid surgery in pregnant women |journal=Arch Surg |volume=144 |issue=5 |pages=399–406; discussion 406 |year=2009 |pmid=19451480 |doi=10.1001/archsurg.2009.48 |url=}}</ref><ref name="pmid9103951">{{cite journal |vauthors=Rosen IB, Korman M, Walfish PG |title=Thyroid nodular disease in pregnancy: current diagnosis and management |journal=Clin Obstet Gynecol |volume=40 |issue=1 |pages=81–9 |year=1997 |pmid=9103951 |doi= |url=}}</ref>


If findings of FNA is suspicious for or diagnostic of PTC in a pregnant woman, LT4 therapy should be considered as a primary therapy in order to keep the TSH in the normal range to avoid thyroid related problems in newborn.<ref name="pmid19451480">{{cite journal |vauthors=Kuy S, Roman SA, Desai R, Sosa JA |title=Outcomes following thyroid and parathyroid surgery in pregnant women |journal=Arch Surg |volume=144 |issue=5 |pages=399–406; discussion 406 |year=2009 |pmid=19451480 |doi=10.1001/archsurg.2009.48 |url=}}</ref><ref name="pmid9103951">{{cite journal |vauthors=Rosen IB, Korman M, Walfish PG |title=Thyroid nodular disease in pregnancy: current diagnosis and management |journal=Clin Obstet Gynecol |volume=40 |issue=1 |pages=81–9 |year=1997 |pmid=9103951 |doi= |url=}}</ref>
==== postoperative RAI remnant ablation ====
==== postoperative RAI remnant ablation ====
If after complete thyroidectomy, still thyroid tissue is found, ablation of the remaining lobe with radioactive iodine can be considered as an alternative way to complete the resection of tissue.<ref name="pmid12490076">{{cite journal |vauthors=Randolph GW, Daniels GH |title=Radioactive iodine lobe ablation as an alternative to completion thyroidectomy for follicular carcinoma of the thyroid |journal=Thyroid |volume=12 |issue=11 |pages=989–96 |year=2002 |pmid=12490076 |doi=10.1089/105072502320908321 |url=}}</ref>
If after complete [[thyroidectomy]], still [[Thyroid|thyroid tissue]] is found, [[ablation]] of the remaining lobe with [[radioactive iodine]] can be considered as an alternative way to complete the resection of tissue.<ref name="pmid12490076">{{cite journal |vauthors=Randolph GW, Daniels GH |title=Radioactive iodine lobe ablation as an alternative to completion thyroidectomy for follicular carcinoma of the thyroid |journal=Thyroid |volume=12 |issue=11 |pages=989–96 |year=2002 |pmid=12490076 |doi=10.1089/105072502320908321 |url=}}</ref>
==== Recombinant human TSH–mediated therapy ====
==== Recombinant human TSH–mediated therapy ====
Indications of recombinant human TSH–mediated therapy:
Indications of recombinant human [[TSH]]–mediated therapy:
* Patients with concurrent co-morbid illnesses that are more prone to adverse effects of iatrogenic hypothyroidism
* Patients with concurrent co-morbid illnesses that are more prone to adverse effects of iatrogenic [[hypothyroidism]]
* Patients with pituitary related disorders that can not produce TSH due to their underlying pituitary problem
* Patients with [[pituitary]] related disorders that can not produce [[TSH]] due to their underlying [[pituitary]] problem
* Patients in whom a delay in therapy might be associated with high morbidities
* Patients in whom a delay in therapy might be associated with high morbidities
It is better to give a higher dosage of recombinant human TSH to these patients to avoid possible adverse effects.<ref name="pmid11701668">{{cite journal |vauthors=Braga M, Ringel MD, Cooper DS |title=Sudden enlargement of local recurrent thyroid tumor after recombinant human TSH administration |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=11 |pages=5148–51 |year=2001 |pmid=11701668 |doi=10.1210/jcem.86.11.8055 |url=}}</ref>
It is better to give a higher dosage of recombinant human [[TSH]] to these patients to avoid possible adverse effects.<ref name="pmid11701668">{{cite journal |vauthors=Braga M, Ringel MD, Cooper DS |title=Sudden enlargement of local recurrent thyroid tumor after recombinant human TSH administration |journal=J. Clin. Endocrinol. Metab. |volume=86 |issue=11 |pages=5148–51 |year=2001 |pmid=11701668 |doi=10.1210/jcem.86.11.8055 |url=}}</ref>
=== Metastases treatment: ===
=== Metastases treatment: ===
Treatment of endocrine metastases should be based on:
Treatment of [[endocrine]] [[metastases]] should be based on:
* Metastatic lesions size
* [[Metastasis|Metastatic]] lesions size
* Avidity for RAI therapy
* Avidity for [[Radioactive iodine uptake|RAI]] therapy
* Response to prior RAI therapy
* Response to prior [[Radioactive iodine uptake|RAI]] therapy
* Absence of metastatic lesions
* Absence of [[metastatic]] lesions
{| class="wikitable"
{| class="wikitable"
! colspan="2" |Metastases
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Metastases
!Treatment
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Treatment
|-
|-
| rowspan="2" |pulmonary metastases
! rowspan="2" |[[Pulmonary]] [[metastases]]
|Micrometastases
!Micrometastases
|
|
* RAI therapy
* [[RAI1|RAI]] therapy
* As long as disease continues to concentrate RAI and respond clinically, repeat every 6–12 months
* As long as disease continues to concentrate [[Radioactive iodine uptake|RAI]] and respond clinically, repeat every 6–12 months
** Multiple repeatedly RAI therapy sessions are shown to be associated with a greater possibility of complete remission
** Multiple repetitive [[RAIU|RAI]] therapy sessions are shown to be associated with a greater possibility of complete remission
|-
|-
|macronodular metastases
!Macronodular [[metastases]]
|
|
* Repetitive RAI in the case of beneficial treatment is demonstrated:
* Repetitive [[Radioactive iodine uptake|RAI]] in the case of beneficial treatment is demonstrated:
** Decrease in the size of the lesions
** Decrease in the size of the lesions
** Decreasing Tg level  
** Decreasing [[thyroglobulin]] level  
* Although repetitive treatments, survival rate is low and it is associated with poor prognosis
* Although repetitive treatments, survival rate is low and it is associated with poor [[prognosis]]
* RAI activity administration methods:
* [[Radioactive iodine uptake|RAI]] activity administration methods:
** Empirical therapy (100–200 mCi)
** [[Empirical]] therapy (100–200 mCi)
** Estimate calculation by lesional dosimetry or dosimetry
** Estimate calculation by lesional [[dosimetry]]
*** To limit wholebody retention to 80 mCi at 48 hours and 200 cGy to the red bone marrow.
*** To limit whole body retention to 80 mCi at 48 hours and 200 cGy to the red [[bone marrow]]
|-
|-
| colspan="2" |brain metastases
! colspan="2" |[[Brain]] [[metastases]]
|
|
* Total surgical resection of CNS metastases
* Total surgical resection of [[CNS]] [[metastases]]
* External beam irradiation for CNS lesions that are not amenable to surgery  
* [[External beam radiotherapy|External beam irradiation]] for [[CNS]] lesions that are not amenable to surgery  
* In case of  Multiple metastases whole brain and spine irradiation should be considered
* In case of  multiple [[metastases]] whole [[brain]] and [[spine]] [[irradiation]] should be considered
|-
|-
| colspan="2" |bone metastases
! colspan="2" |[[Bone]] [[metastases]]
|
|
* Complete surgical resection of isolated symptomatic metastases
* Complete surgical resection of isolated [[symptomatic]] [[metastases]]
* RAI therapy of iodine-avid bone metastases
* [[Radioactive iodine uptake|RAI]] therapy of iodine-avid [[bone metastases]]
|}
|}


=== Complications ===
=== Complications ===


===== Radioactive iodine therapy: 24751702 =====
===== Radioactive iodine therapy: <ref name="pmid24751702">{{cite journal |vauthors=Fard-Esfahani A, Emami-Ardekani A, Fallahi B, Fard-Esfahani P, Beiki D, Hassanzadeh-Rad A, Eftekhari M |title=Adverse effects of radioactive iodine-131 treatment for differentiated thyroid carcinoma |journal=Nucl Med Commun |volume=35 |issue=8 |pages=808–17 |year=2014 |pmid=24751702 |doi=10.1097/MNM.0000000000000132 |url=}}</ref>=====
Early complications:
Early complications:
* Gastrointestinal symptoms
* [[Gastrointestinal]] symptoms
* Radiation thyroiditis
* Radiation thyroiditis
* Sialadenitis/xerostomia
* [[Sialadenitis]]/[[xerostomia]]
* Bone marrow suppression
* [[Bone marrow suppression]]
* Gonadal damage
* [[Gonadal]] damage
* Dry eye
* [[Dry eye]]
* Nasolacrimal duct obstruction.
* [[Nasolacrimal duct]] obstruction
Late complications:
Late complications:
* Secondary cancers
* Secondary [[cancers]]
* Pulmonary fibrosis
* [[Pulmonary fibrosis]]
* Pulmonary pneumonitis (rare)
* [[Pneumonitis|Pulmonary pneumonitis]] (rare)
* Permanent bone marrow suppression
* Permanent [[bone marrow suppression]]
* Genetic effects
* [[Genetic]] effects


==References==
==References==

Latest revision as of 17:33, 2 November 2017


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

In case of active hot thyroid nodules that produce thyroid hormones, antithyroid drugs should be administered, that include beta-blockers, antithyroid drugs (methimazole,carbimazole,propylthiouracil), radioactive iodine, and thyroidectomy. If the nodule excision treatment (lobectomy, isthmectomy, and total thyroidectomy) is not curative, then treatment with postoperative radioactive iodine (RAI) remnant ablation and recombinant human TSH–mediated therapy is recommended.

Medical Therapy

 
 
 
 
 
 
 
 
 
 
 
 
Thyroid nodule
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Malignant
 
 
 
 
 
 
 
 
 
 
 
Benign
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radioiodine therapy
 
 
 
 
 
 
 
 
 
 
 
Hyrperthyroidism evaluation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hyperthyroidism
 
Euthyroid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antithyroid drugs
 
No medical treatment required
Monitor nodule
 
 
 
 

In case of active hot thyroid nodule that produce thyroid hormones, antithyroid drugs should be administered. The table below summarizes the treatment options in case of hot thyroid nodules:

Treatment Mechanism Route of administration Advantages Disadvantages Special considerations
Beta-blockers Oral
  • Does not influence course of disease
Antithyroid drugs (methimazole,

carbimazole,propylthiouracil)

Given as either a single, high fixed dose (e.g., 10–30 mg of methimazole or 200–600 mg of propylthiouracil daily)

and adjusted as euthyroidism is achieved or combined with thyroxine to prevent hypothyroidism (“block–replace” regimen)

  • Outpatient therapy
  • Low risk of hypothyroidism
  • No radiation hazard or surgical risk
  • Frequent testing required unless block-replacement therapy is used
  • Minor side effects in ≤5% of patients (rash, urticaria, arthralgia, fever, nausea, abnormalities of taste and smell)
 Major side effects usually occur within first 3 months of therapy:
Radioactive iodine

(iodine-131)

Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations
  • Normally outpatient procedure
  • Definitive therapy
  • Low cost
  • Few side effects
  • Effectively reduces nodule size
Thyroidectomy
  • Most or all thyroid tissue is removed surgically
 -----
  • Recurrence may happen in the case of metastasis and high stages of the cancer
  • No radiation hazard
  • Definitive histologic results
  • Rapid relief of pressure symptoms
  • Should just be performed in patients with high suspicion towards malignancy

Medical therapy goals in thyroid malignancies and differentiated thyroid cancers (DTC) include:

  • To remove:
    • To remove primary tumor
    • To eliminate the disease that has extended beyond the thyroid capsule
    • To remove involved cervical lymph nodes
    • To minimize treatment-related morbidity
    • To permit accurate staging of the disease
    • To facilitate postoperative treatment with radioactive iodine where appropriate
    • To permit accurate long-term surveillance for disease recurrence
    • To minimize the risk of disease recurrence and metastatic spread
  • Both RAI whole-body scanning (WBS) and measurement of serum thyroglobulin are affected by residual normal thyroid tissue. Where these approaches are utilized for long-term monitoring, near-total or total thyroidectomy is required.[4]
  • There is a high risk of complication in thyroid nodule surgery. The most important factors determining surgical complications are:[6]
    • The extent of surgery
    • The experience of the surgeon
  • Some experts recommend thyroid hormone administration in the case of benign thyroid nodule in iodine insufficient areas as a treatment. Thyroid hormone administration in larger than needed doses that decrease the serum TSH to subnormal levels, may lead to a decrease in nodule size and may be beneficial in regions of the world with borderline low iodine intake, as it may prevent new nodule formation. However, in iodine sufficient areas, there are insufficient evidences that administrating thyroid hormone may have a beneficial effect on benign thyroid nodules.

postoperative RAI remnant ablation

If after complete thyroidectomy, still thyroid tissue is found, ablation of the remaining lobe with radioactive iodine can be considered as an alternative way to complete the resection of tissue.[11]

Recombinant human TSH–mediated therapy

Indications of recombinant human TSH–mediated therapy:

  • Patients with concurrent co-morbid illnesses that are more prone to adverse effects of iatrogenic hypothyroidism
  • Patients with pituitary related disorders that can not produce TSH due to their underlying pituitary problem
  • Patients in whom a delay in therapy might be associated with high morbidities

It is better to give a higher dosage of recombinant human TSH to these patients to avoid possible adverse effects.[12]

Metastases treatment:

Treatment of endocrine metastases should be based on:

Metastases Treatment
Pulmonary metastases Micrometastases
  • RAI therapy
  • As long as disease continues to concentrate RAI and respond clinically, repeat every 6–12 months
    • Multiple repetitive RAI therapy sessions are shown to be associated with a greater possibility of complete remission
Macronodular metastases
  • Repetitive RAI in the case of beneficial treatment is demonstrated:
    • Decrease in the size of the lesions
    • Decreasing thyroglobulin level
  • Although repetitive treatments, survival rate is low and it is associated with poor prognosis
  • RAI activity administration methods:
    • Empirical therapy (100–200 mCi)
    • Estimate calculation by lesional dosimetry
      • To limit whole body retention to 80 mCi at 48 hours and 200 cGy to the red bone marrow
Brain metastases
Bone metastases

Complications

Radioactive iodine therapy: [13]

Early complications:

Late complications:

References

  1. ↑ Wang TS, Dubner S, Sznyter LA, Heller KS (2004). "Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes". Arch. Otolaryngol. Head Neck Surg. 130 (1): 110–3. doi:10.1001/archotol.130.1.110. PMID 14732779.
  2. ↑ Hay ID, Bergstralh EJ, Goellner JR, Ebersold JR, Grant CS (1993). "Predicting outcome in papillary thyroid carcinoma: development of a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989". Surgery. 114 (6): 1050–7, discussion 1057–8. PMID 8256208.
  3. ↑ Ito Y, Miyauchi A (2010). "Thyroidectomy and lymph node dissection in papillary thyroid carcinoma". J Thyroid Res. 2011: 634170. doi:10.4061/2011/634170. PMC 2989453. PMID 21113383.
  4. ↑ Mazzaferri EL (1999). "An overview of the management of papillary and follicular thyroid carcinoma". Thyroid. 9 (5): 421–7. doi:10.1089/thy.1999.9.421. PMID 10365671.
  5. ↑ Kim TH, Yang DS, Jung KY, Kim CY, Choi MS (2003). "Value of external irradiation for locally advanced papillary thyroid cancer". Int. J. Radiat. Oncol. Biol. Phys. 55 (4): 1006–12. PMID 12605980.
  6. ↑ Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon TA, Udelsman R (1998). "The importance of surgeon experience for clinical and economic outcomes from thyroidectomy". Ann. Surg. 228 (3): 320–30. PMC 1191485. PMID 9742915.
  7. ↑ Lin JD, Chao TC, Huang MJ, Weng HF, Tzen KY (1998). "Use of radioactive iodine for thyroid remnant ablation in well-differentiated thyroid carcinoma to replace thyroid reoperation". Am. J. Clin. Oncol. 21 (1): 77–81. PMID 9499265.
  8. ↑ Esnaola NF, Cantor SB, Sherman SI, Lee JE, Evans DB (2001). "Optimal treatment strategy in patients with papillary thyroid cancer: a decision analysis". Surgery. 130 (6): 921–30. doi:10.1067/msy.2001.118370. PMID 11742318.
  9. ↑ Kuy S, Roman SA, Desai R, Sosa JA (2009). "Outcomes following thyroid and parathyroid surgery in pregnant women". Arch Surg. 144 (5): 399–406, discussion 406. doi:10.1001/archsurg.2009.48. PMID 19451480.
  10. ↑ Rosen IB, Korman M, Walfish PG (1997). "Thyroid nodular disease in pregnancy: current diagnosis and management". Clin Obstet Gynecol. 40 (1): 81–9. PMID 9103951.
  11. ↑ Randolph GW, Daniels GH (2002). "Radioactive iodine lobe ablation as an alternative to completion thyroidectomy for follicular carcinoma of the thyroid". Thyroid. 12 (11): 989–96. doi:10.1089/105072502320908321. PMID 12490076.
  12. ↑ Braga M, Ringel MD, Cooper DS (2001). "Sudden enlargement of local recurrent thyroid tumor after recombinant human TSH administration". J. Clin. Endocrinol. Metab. 86 (11): 5148–51. doi:10.1210/jcem.86.11.8055. PMID 11701668.
  13. ↑ Fard-Esfahani A, Emami-Ardekani A, Fallahi B, Fard-Esfahani P, Beiki D, Hassanzadeh-Rad A, Eftekhari M (2014). "Adverse effects of radioactive iodine-131 treatment for differentiated thyroid carcinoma". Nucl Med Commun. 35 (8): 808–17. doi:10.1097/MNM.0000000000000132. PMID 24751702.

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