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Difficult thyroid cancer cases

Difficult thyroid cancer cases. Ampica Mangklabruks MD 10 May 2012. Case 1 : A 50 year-old -man. Diagnosed as papillary thyroid carcinoma since yr 2000

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Difficult thyroid cancer cases

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  1. Difficult thyroid cancer cases AmpicaMangklabruks MD 10 May 2012

  2. Case 1 : A 50 year-old -man • Diagnosed as papillary thyroid carcinoma since yr 2000 • Near total thyroidectomy in yr 2000, cervical Lymph node positive for metastasis . (with surgical complications: Hypoparathyroidism and TVC paralysis) • Received radioactive iodine complete ablation • Bilateral lung metastasis was detected by WBS in yr 2005 • Plain Chest film- negative • CT chest : not done

  3. Case 1 ; Pre treatment WBS

  4. Pulmonary metastases (1) Key criteria for theraputic decision • Size of metastatic lesion • Macronodular detected by chest x-ray • Micronodular detected by chest CT • lesions can not detect by CT (only WBS positive) • Avidity of RAI • Stability of metastatic lesion • Pulmonary fibrosis from radiation pneumonitis (rare)

  5. Pulmonary metastases (2) • Pulmonary micrometastases treated with RAI (Recgr A) highest rate of complete remission • May use empiric dose (100-200mCi) or dosimetry • Macronodular met  use RAI if iodine avid (continue if benefit can be demonstatedie size reduction, Tg decreased ) but complete remission is not common. • Non-RAI –avid pulmonary metastases : • Micronodular : RAI and post treatment scan • Macronodular : RAI usually no benefit, consider chemotherapy , Tyrosine Kinase Inhibitor ,palliative treatment

  6. Case 1 • He received RAI, 150 mCi each times , for 6-7 times (every 6-12 months) • total dose of I131 = 1000 millicurie • In June 2010: WBS still show residual bilat lung metastasis • Thyroglobulin= 18.6, anti TG= 269

  7. Dose and methods of administering I131 for locoregional or metastatic disease • The optimal therapeutic dose is uncertain and controversial • Three approach • Empiric fixed dose • Therapy determined by body and blood dosimetry (upper limit) • Quantitative tumor dosimetry • No study to compare the outcom available • Dosimetry usually reserved for pt with distant metastasis, renal insufficiency

  8. Long term complications of RAI • Salivary gland damage, dental caries, nasolacrimal duct obstruction. • Secondary malignancies and leukemia ( increased risk at accumulative dose 500-600 mCi)

  9. Case 1 • Internal dosimetry : rapid washout • Received lithium carbonate (300) , monitoring blood level (blood level after receiving 900mg/d =0.82 (0.6-1.2 mmol/L) • Repeat dosimetry : delayed wash out • Total dose of RAI not exceed safty dose at lung and marrow. • Repeat I131 150 millicurie with lithium (Feb 2011)

  10. Lithium and thyroid cancer • Action : inhibit thyroid hormone release without impairing iodine uptake Enhance I131 retention in normal thyroid and tumor cell • Koong SS et al : lithium can increase estimate I131 radiation dose in metastatic tumor by 2 fold (tumor which rapidly clear iodine) • Liu YY et al can not demonstrate clinical benefit (12 pt) • ATA recommendation : Data insufficient to recommend lithium therapy ( rating I)

  11. Case 1 • Post treatment scan : good uptake at both lung • Follow up WBS september2011 : complete I131 ablation • Thyroglobulin level

  12. Case 1 ; Post treatment WBS

  13. Case 1 : remission

  14. Case 2: a 49-year-old woman • A history of thyroid nodule for 30 years, getting bigger last 5 years. • I yr ago: Rt shoulder pain , mass found at scalp. Difficulty in breathing. No hoarseness, no difficulty in swallowing. • Physical Exam: thyroid nodule 10 cm diameter, scalp nodule 5 cm, swelling mass Rt upper arm. • FNA at scalp : Metastasis follicular carcinoma • FNA thyroid nodule: Follicular neoplasm

  15. Rthumerus :Plain film : osteolytic lesion Rt proximal humerus, Impending pathological fracture

  16. CT results • Lt Thyroid mass 6.6x8.1x10.8cms.Rightward displacement of trachea and esophagus. Posterior displacement of carotid artery.Part of mass can not be separates from trachea, esophagus, and carotid artery. • Skull metas right high parietal bone. • Bone scan; multiple bone met at skull, rthumerous, ipsilateral distal clavicle, rt scapula and Lt pubic bone

  17. Treatment of bone metastases • Key criteria for therapeutic decision: • Presence of or risk of pathologic fracture, particularly in weight bearing structure • Risk of neurological compromise from vertebral lesions • Presence of pain • Avidity of RAI uptake • Potential significant marrow exposure from radiation (RAI- avid pelvic metastases)

  18. Treatment of bone metastases • Complete surgical resection for isolate lesion • RAI therapy improve survival (but rarely curative) • External radiation for lesion with severe pain, fracture, neurological complication external radiation and glucocorticoid. • Others such as intra-arterial embolization, radiofrequency ablation, periodic pamidronate or zoledronate infusion.etc

  19. How to manage this patient?? • RAI ?? : Need thyroidectomy first • Thyroidectomy?? Possible?? • Palliative?? • Rthumerous : Intralesional curette and prophylactic fixation

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