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RECOMMENDATIONS FOR RADIOIODINE TREATMENT OF THYROID CANCER.
The following guidelines update the treatment and follow-up of thyroid cancer of follicular origin. They were drawn up by the Endocrinology Work Group of the French Society of Nuclear Medicine (SFMN: authors SZ, ALG, SL, JC, SB, IK,MET, EH, DT) and experts appointed by five other scientific societies: French Society of Endocrinology (SFE: LL, CB, LG),French Society of Pathology (SFP: AAG), French Society of Clinical Biology (SFBC: PJL), French-speaking Association of Endocrine Surgery (AFCE: FS, EM), and French Society of Otorhinolaryngology and Head and Neck Surgery (SFORL:RG).
Recommendation 1 (R1) Radioactive iodine therapy is not recommended in patients with unifocal pT1a tumor, or multi-focal pT1a with total lesion size ≤ 1 cm, without extrathyroidal extension, N0/NX: strong recommendation, moderate quality evidence
Recommendation 2 (R2) In multifocal pT1a with total lesion size > 1 cm orpT1b, without extrathyroidal extension, N0/Nx, inpT1a with minor extrathyroidal extension (mEET),N0/Nx and in follicular carcinoma without vascular invasion, the use of radioactive iodine is optional. If 131 I therapy is administered, low activity is to be preferred and rhTSH is to be preferred to thyroid hormone withdrawal : Strong recommendation, moderate quality evidence
Recommendation 3 (R3) In other patients with low risk of relapse (apart from R1 and R2), including pT1bNx/N0 with minor extrathyroidal extension, radioactive iodine treatment is recommended: weak recommendation, low quality evidence
.Recommendation 4 (R4) In these patients (R3), low131I activity is to be preferred and rhTSH is to be preferred to thyroid hormone
Recommendation 5 (R5) Radioactive iodine is recommended in IR patients. Either rhTSH or thyroid hormone withdrawal can be used. Strong recommendation, moderate quality evidence.
Recommendation 6-a (R6a) In case of a single extranodal IR criterion, low to high131I activity can be used. Strong recom-mendation, moderate quality evidence.
Recommendation 6-b (R6b) In case of multiple IR criteria or additional factors of poor prognosis (advanced age, aggressive histotype and/or presence of lateral lymph-node involvement [pN1b]), high131I activity may be considered. Strong recommendation, moderate quality evidence.
Recommendation 7 (R7) Radioactive iodine therapy is systematically indicated. High 131I activity can be considered. Strong recommendation, moderate quality evidence. Either thyroid hormone withdrawal or rhTSHcan be used for patient preparation. Weak recommendation, low quality evidence.
Recommendation 8 (R8) High131I activity is recommended. Strong recommendation, moderate quality evidence. Either thyroid hormone withdrawal or rhTSHcan be used for patient preparation. Weak recommendation, low quality evidence.
Recommendation 9 (R9) Radioactive iodine therapy is systematically indicated in HR patients. Strong recommendation, moderate quality evidence
Recommendation 9b (R9b) The recommended schedule includes high administered 131 I activity and thyroid hormone withdrawal. Strong recommendation, moderate quality evidence.
Recommendation 10 (R10)In case of biochemical evidence of dis-ease without structural abnormality on anatomic imaging, a second131I treatment can be recommended for diagnostic and therapeutic purposes in the presence of the following criteria:
Recommendation 11 (R11) In case of biochemical evidence of disease with abnormalities on functional (18F-FDG PET/CT) or anatomic imaging,131I administration may be considered for diagnostic purposes, in order to determine whether the lesions are iodine avid or not, and for therapeutic purposes, especially for subcentimeter metastatic lymph nodes or distant metastases. Strong recommendation, low-quality evidence.Post-treatment131I scan and intraoperative detection can be used to guide and optimize reoperative surgery
Recommendation 12 (R12)At least one additional131I treatment is recommended, at 100 mCi, preferably after thyroid hormone withdrawal, in presence of biochemical evidence of disease (with or without structural disease) after a targeted therapeutic approach (e.g., surgery, external radiotherapy). Strong recommendation, low-quality evidence.131I treatment may be repeated, depending on tumor response.
Recommendation 13 (R13)In non resectable loco regional disease [5,40], at least one RAI treatment is recommended, at an empiric activity level of 100 mCi, preferably after thyroid hormone withdrawal. Treatment may be repeated, depending on tumor response. Strong recommendation, low quality evidence.
Recommendation 14 (R14) Metastatic disease should be treated under thyroid hormone withdrawal [51–54]. Strong recommendation, moderate quality evidence. In case of risk of poor tolerance of hypothyroidism or hypopituitarism, rhTSH may be used (off-label, after validation by multidisciplinary team meeting).
Recommendation 15 (R15)In case of diffuse or isolated lung micro-metastases, curative RAI therapy is indicated, with several cycles of therapy until disappearance of metastatic foci on post-therapy CT scan. There commended schedule is a 6-monthly treatment regimen for the 1–2 years following initial therapy then yearly or at longer intervals depending on treatment response and tolerance .The personalized schedule is validated in a local multidisciplinary team meeting, or at regional or national level for difficult cases. Treatment is performed after thyroid hormone withdrawal; if this is contraindicated, off label rhTSH may be proposed, and preferably validated in a multidiscciplinary team meeting. Strong recommendation, moderate quality evidence.
Recommendation 16 (R16)In case of pulmonary macro-metastases (supra-centimeter tumor), iterative131I therapy, at100–200 mCi (3.7–7.4 GBq) under thyroid hormone withdrawal is indicated for as long as uptake persists on post therapy 131 I scan and if there is clear clinical, scintigraphic, morphologic or biochemical-cal response. Treatment is performed after thyroid hormone withdrawal. If thyroid hormone withdrawal is contraindicated, off-label rhTSH may be proposed, and preferably validated in a multidisciplinary team meeting. Weak recommendation, low quality evidence.
Thermoablation may also be considered in addition to131I treatment for pulmonary macronodules few in number and measuring < 3 cm.
Recommendation 17 (R17) In case of bone metastases, RAI therapy is indicated for as long as uptake persists on post-therapy 131 I scan and if there is clinical, scintigraphic, morphologic or biochemical response, and should be systematically accompanied by precise radiological evaluation and neurologic risk-pain-stability assessment for each location. Local consolidation treatment or surgical resection may be necessary prior to iodine-131 therapy . Strong recommendation, moderate quality evidence.
Recommendation 18 (R18) In case of bone metastases, iterative131I therapy, at 100–200 mCi (3.7–7.4 GBq) per cycle is performed under thyroid hormone withdrawal. Weak recommendation, low-quality evidence.
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