Management of Differentiated Thyroid Cancer with Rising Thyroglobulin and Negative Diagnostic Radioiodine Whole Body Scan

• Published in: Clinical oncology (Royal College of Radiologists (Great Britain)) Vol. 22; no. 6; pp. 438 - 447
• Main Author: Chao, M
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.08.2010
• Subjects: Biomarkers, Tumor - blood; Controlled Clinical Trials as Topic; Empirical radioiodine therapy; Hematology, Oncology and Palliative Medicine; Humans; Iodine Radioisotopes - therapeutic use; negative diagnostic whole body scan; Radiology; Radionuclide Imaging; Radiopharmaceuticals - therapeutic use; Randomized Controlled Trials as Topic; rising thyroglobulin; Thyroglobulin - blood; Thyroid Neoplasms - blood; Thyroid Neoplasms - diagnostic imaging; Thyroid Neoplasms - pathology; Thyroid Neoplasms - radiotherapy; Whole-Body Counting; rising thyroglobulin; negative diagnostic whole body scan; Empirical radioiodine therapy
• ISSN: 0936-6555; 1433-2981
• DOI: 10.1016/j.clon.2010.05.005

Abstract Background Differentiated thyroid carcinoma (DTC) with rising thyroglobulin (Tg) level and negative radioiodine whole body scan results has been observed in follow-up studies. The management of this condition remains controversial. Most studies support blind131 I treatment while others oppose this approach. Aims To assess the effects of131 I therapy for DTC with rising Tg and negative scan results. Selection criteria Randomised controlled clinical trials, prospective controlled clinical trials and any trials using131 I treatment or no treatment for Tg-positive and radioiodine-negative disease were included in this review. Results Due to the lack of any suitable randomised or prospective controlled trials in this area, it was not possible to undertake a meta-analysis. Eighteen trials were retrieved for further overall assessment. Of 438 patients from 16 studies who were treated empirically with131 I for Tg-positive and radioiodine-negative disease, 267 (62%) displayed pathological uptake in the thyroid bed, lungs, bone, mediastinum and lymph nodes. In studies in which data were available for serum Tg levels during thyroid-stimulating hormone (TSH) suppression therapy or TSH withdrawal, 188 of 337 patients (56%) showed a decrease in serum Tg. Of 242 patients from five studies who received no specific treatment for Tg-positive and radioiodine-negative disease, 106 (44%) showed spontaneous normalisation and a significant decrease in serum Tg. Conclusions The currently available evidence is insufficient for reliable assessment of the potential of131 I treatment for DTC with elevated Tg and negative scan results. A decrease in serum Tg in 62% of patients with DTC with elevated Tg and negative scan results suggests that131 I therapy has a therapeutic effect for more than one-half of patients when the Tg level is considered an index of tumour burden. However, considering that 44% of patients with DTC with elevated Tg and negative scan results showed spontaneous normalisation and a significant reduction in serum Tg without any specific treatment,131 I therapy should be individualised according to clinical characteristics. Other diagnostic techniques are strongly recommended for patients with Tg-positive and radioiodine-negative disease. If these diagnostic results are positive, treatment options such as surgery, external radiotherapy and tumour embolisation should be considered. If diagnostic results are negative, one course of131 I treatment may be considered in high-risk patients with serum Tg >10 ng/mL after TSH withdrawal or >5 ng/mL under recombinant human TSH stimulation. No further131 I therapy is indicated for patients with a negative post-therapy radioiodine scan.