Selective use of radioactive iodine (RAI) in thyroid cancer: no longer “one size fits all”

• Published in: European journal of surgical oncology Vol. 44; no. 3; pp. 348 - 356
• Main Authors: Marti, Jennifer L., MD, Morris, Luc G.T., MD, MSc, Ho, Allen S., MD
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.03.2018
• Subjects: ATA Guidelines; Biomarkers, Tumor - analysis; Combined Modality Therapy; De-escalation; Decision Making; Hematology, Oncology and Palliative Medicine; Humans; Iodine Radioisotopes - therapeutic use; Patient Selection; Practice Guidelines as Topic; Radioactive iodine; Radiotherapy Dosage; Risk Assessment; Risk Factors; Surgery; Thyroid cancer; Thyroid Neoplasms - radiotherapy; Thyroid Neoplasms - surgery; Thyroidectomy; Thyroidectomy - methods; radioactive iodine; de-escalation; ATA Guidelines; thyroidectomy; thyroid cancer; De-escalation; Thyroid cancer; Radioactive iodine; Thyroidectomy
• ISSN: 0748-7983; 1532-2157
• DOI: 10.1016/j.ejso.2017.04.002

Abstract A remarkable, evidence-based trend toward de-escalation has reformed the practice of radioactive iodine (RAI) administration for thyroid cancer patients. Updated guidelines have supported both decreased RAI doses for select populations, as well as expanded definitions of low-risk and intermediate-risk patients that may not require RAI. Correspondingly, there is now increased flexibility for hemithyroidectomy without need for RAI, and relaxed TSH suppression targets for low-risk thyroidectomy patients. Clinical judgment remains indispensable where multiple risk factors co-exist that individually are not indications for RAI. This is especially salient in intermediate-risk patients with a less than excellent response to therapy, determined through thyroglobulin and ultrasound surveillance. Such judgement, however, may lead to patterns of inappropriate RAI practices or overuse with little benefit to the patient and unnecessary harm. A multidisciplinary, risk-adapted approach is ever more important and obliges the surgeon to understand the likelihood that their patients will receive RAI. The risks and benefits of RAI, its evolved role in contemporary guidelines, and current patterns of use among endocrinologists are reviewed, as well as the practical implications for thyroid surgeons.