Management of Differentiated Thyroid Cancer: The Standard of Care

Anca M. Avram; Katherine Zukotynski; Helen Ruth Nadel; Luca Giovanella

doi:10.2967/jnumed.121.262402

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FIGURE 1.
Radioiodine theranostics for 63-y-old man with 2.2-cm regionally advanced papillary thyroid carcinoma and of 11 lymph nodes dissected, all 11 were positive for metastasis, in surgical specimen of total thyroidectomy. (A) Diagnostic 37-MBq (1 mCi) ¹³¹I WBS, anterior projection, depicts multifocal neck activity and diffuse lung activity. (B and C, different anatomic levels within the neck, depicting lymph nodal metastases located in different cervical compartments) Neck SPECT/CT demonstrates iodine-avid soft-tissue nodules consistent with cervical nodal metastases. (D) Chest SPECT/CT demonstrates diffuse lung activity and branching pulmonary vasculature without definite lung nodules identified. Patient received dosimetry-guided 12.6-GBq (340 mCi) ¹³¹I treatment. (E) On posttherapy WBS at 3 d, anterior projection demonstrates therapeutic ¹³¹I localization to cervical lymph nodal metastases and diffuse miliary pulmonary metastatic disease.
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FIGURE 2.
Radioiodine theranostics for 66-y-old woman with 2.5-cm widely invasive follicular thyroid carcinoma with osseous metastatic disease. (A–F) Diagnostic 37-MBq (1 mCi) ¹³¹I WBS, anterior projection (A), depicts multifocal skeletal activity, which is further characterized on SPECT/CT as iodine-avid lytic osseous metastases involving right humerus (B), vertebrae (C), pelvis (D) left femoral neck (E), and left femoral diaphysis (F). Patient received dosimetry-guided 12-GBq (325 mCi) ¹³¹I treatment. (G) Posttherapy WBS, anterior projection, obtained at 2 d demonstrates therapeutic ¹³¹I targeting of extensive iodine-avid multifocal osseous metastatic disease involving axial and proximal appendicular skeleton, with increased lesion conspicuity and numerous new foci detected as compared with diagnostic scan.

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TABLE 1

Suggested Framework for ¹³¹I Therapy for DTC (28)

Strategy	Prescribed ¹³¹I activity	Clinical context
Risk-adapted ¹³¹I therapy	1.11–1.85 GBq (30–50 mCi)	Remnant ablation
	1.85–3.7 GBq (50–100 mCi)	Adjuvant treatment
	3.7–5.6 GBq (100–150 mCi)	Treatment of small-volume locoregional disease
	5.6–7.4 GBq (150–200 mCi)	Treatment of advanced locoregional disease or small-volume distant metastatic disease
Whole-body/blood dosimetry	≥7.4 GBq (≥200 mCi), maximum tolerable safe activity	Treatment of diffuse distant metastatic disease

All pediatric therapeutic ¹³¹I activities are adjusted as multiplier based on 70-kg adult body weight.

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TABLE 2

Response to Treatment in DTC Patients: Assessment Criteria (4)

Response	Criteria
Excellent (complete)	No clinical, biochemical, or structural evidence of disease; definition: negative imaging and either suppressed thyroglobulin < 0.2 ng/mL or stimulated thyroglobulin < 1 ng/mL
Biochemically incomplete	Abnormal thyroglobulin (suppressed thyroglobulin > 1 ng/mL or stimulated thyroglobulin > 10 ng/mL or rising anti–thyroglobulin antibody levels in absence of localizable disease [i.e., negative imaging])
Structurally incomplete	Persistent or new locoregional or distant metastases (any thyroglobulin)
Indeterminate	Nonspecific biochemical findings (suppressed thyroglobulin = 0.2–1 ng/mL or stimulated thyroglobulin = 1–10 ng/mL or stable/declining anti–thyroglobulin antibody levels) or structural findings that cannot be confidently classified as benign or malignant