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Nuklearmedizin 2022; 61(02): 87-96
DOI: 10.1055/a-1783-8154
Position Paper

Individualized treatment of differentiated thyroid cancer: The value of surgery in combination with radioiodine imaging and therapy – A German position paper from Surgery and Nuclear Medicine

Article in several languages: English | deutsch
Matthias Schmidt
1   Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
12   Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
13   Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
,
Peter Bartenstein
2   Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
13   Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
,
Jan Bucerius
3   Department of Nuclear Medicine, University Medical Center Göttingen, Göttingen, Germany
,
Markus Dietlein
1   Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
13   Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
,
Alexander Drzezga
1   Department of Nuclear Medicine, Faculty of Medicine, University Hospital of Cologne, Cologne, Germany
,
Ken Herrmann
4   Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen and German Cancer Consortium (DKTK), Essen, Germany
,
Constantin Lapa
5   Nuclear Medicine, Faculty of Medicine, University of Augsburg, Augsburg, Germany
11   Member of the Board, German Society of Nuclear Medicine (DGN e. V.)
,
Kerstin Lorenz
6   Department of Visceral, Vascular and Endocrine Surgery, Martin Luther University of Halle Wittenberg, Faculty of Medicine, Halle, Germany
14   Member of the surgical working group for endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)
,
Thomas J. Musholt
7   Section of Endocrine Surgery, Department of General, Visceral and Transplantation Surgery, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
14   Member of the surgical working group for endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)
,
James Nagarajah
8   Department of Medical Imaging, Nuclear Medicine, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherland
12   Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
13   Guideline Committee, German Society of Nuclear Medicine (DGN e. V.)
,
Christoph Reiners
9   Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
,
Carsten O. Sahlmann
3   Department of Nuclear Medicine, University Medical Center Göttingen, Göttingen, Germany
12   Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
,
Michael C. Kreissl
10   Division of Nuclear Medicine, Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
12   Thyroid Committee, German Society of Nuclear Medicine (DGN e. V.)
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Correction: Individualized treatment of differentiated thyroid cancer: The value of surgery in combination with radioiodine imaging and therapy – A German position paper from Surgery and Nuclear MedicineNuklearmedizin eFirst
DOI: 10.1055/a-1824-1280

Abstract

A consensus statement about indications for post-surgical radioiodine therapy (RIT) in differentiated thyroid cancer patients (DTC) was recently published by the European Thyroid Association (ETA) [1]. This publication discusses indications for RIT on the basis of an individual risk assessment. Many of the conclusions of this consensus statement are well founded and accepted across the disciplines involved. However, especially from the perspective of nuclear medicine, as the discipline responsible for indicating and executing RIT, some of the recommendations may require further clarification with regard to their compatibility with established best practice and national standards of care. Assessment of the indications for RIT is strongly dependent on the weighing up of benefits and risks. On the basis of longstanding clinical experience in nuclear medicine, RIT represents a highly specific precision medicine procedure of proven efficacy with a favorable side-effect profile. This distinguishes RIT significantly from other adjuvant oncological therapies and has resulted in the establishment of this procedure as a usually well-tolerated, standard safety measure. With regard to its favorable risk/benefit ratio, this procedure should not be unnecessarily restricted, in the interest of offering reassurance to the patients. Both patients’ interests and regional/national differences need to be taken into account. We would therefore like to comment on the recent consensus from the perspective of authors and to provide recommendations based on the respective published data.

Modified recommendation 1

The decision to proceed with post-operative RIT should be based on the recommendation of an interdisciplinary tumor board incorporating initial prognostic indicators for thyroid cancer related death and recurrence, including not only the surgical and pathology report, and patient age but also the results of postoperative laboratory and imaging results. The patient should be involved in the decision-making process (“shared decision making”).

Modified recommendation 2

The use of I-131 therapy as adjuvant treatment or treatment of known disease is indicated for patients in the high risk of recurrence category or with known structural disease. In this setting, high activities (≥ 3700 MBq) of radioiodine are preferred over low activities. Individual dosimetry may be considered.

Modified recommendation 3

In the intermediate-risk category, RIT therapy is indicated.

Modified recommendation 4

In low-risk patients, RIT therapy should be performed in patients at stages pT1b-2, N0–1; in stage pT1a RIT may be performed but under consideration of additional risk modifiers (e. g. multifocality, aggressive histology, BRAF mutation).

Modified recommendation 5

Recombinant human TSH and thyroid hormone withdrawal (THW) can both be used for patient preparation for RIT therapy.

Modified recommendation 6

Activities of 1–3.7 GBq may be chosen for ablative/adjuvant treatment, if there is no strong suspicion of residual tumor or of distant metastases. Activities of 1.85–3.7 GBq are favoured under the aspect of adjuvant RIT.

Modified recommendation 7

A postoperative diagnostic functional scan can be helpful as it has been shown to allow individualized patient management.

Modified recommendation 8

A low-iodine diet should be followed for two weeks prior to RIT. Iodine-containing drugs should be avoided.

Geänderte Empfehlung 1

Die Entscheidung, mit der postoperativen RIT fortzufahren, sollte auf der Empfehlung eines interdisziplinären Tumorboards beruhen, das erste prognostische Indikatoren für Schilddrüsenkrebs-bedingte Todesfälle und Rezidive berücksichtigt, wozu nicht nur der chirurgische und pathologische Bericht und das Alter des Patienten gehören, sondern auch die Ergebnisse der postoperativen Labor- und Bildgebungsuntersuchungen. Der Patient sollte in den Entscheidungsprozess einbezogen werden („shared decision making“).

Geänderte Empfehlung 2

Der Einsatz der I-131-Therapie als adjuvante Behandlung oder zur Behandlung einer bekannten Erkrankung ist bei Patienten mit hohem Rezidivrisiko oder mit bekannter struktureller Erkrankung angezeigt. In diesem Zusammenhang sind hohe Radiojodaktivitäten (≥ 3700 MBq) gegenüber niedrigen Aktivitäten vorzuziehen. Eine individuelle Dosimetrie kann in Betracht gezogen werden.

Geänderte Empfehlung 3

In der mittleren Risikokategorie ist eine RIT-Therapie angezeigt.

Geänderte Empfehlung 4

Bei Patienten mit niedrigem Risiko sollte die RIT-Therapie in den Stadien pT1b-2, N0–1 durchgeführt werden; im Stadium pT1a kann die RIT durchgeführt werden, allerdings unter Berücksichtigung zusätzlicher Risikomodifikatoren (z. B. Multifokalität, aggressive Histologie, BRAF-Mutation).

Geänderte Empfehlung 5

Rekombinantes humanes TSH und Schilddrüsenhormonentzug (THW) können beide zur Vorbereitung der Patienten auf die RIT-Therapie verwendet werden.

Geänderte Empfehlung 6

Aktivitäten von 1–3,7GBq können für die ablative/adjuvante Behandlung gewählt werden, wenn kein dringender Verdacht auf einen Resttumor oder auf Fernmetastasen besteht. Aktivitäten von 1,85–3,7GBq werden unter dem Aspekt der adjuvanten RIT bevorzugt.

Geänderte Empfehlung 7

Ein postoperativer diagnostischer Funktionsscan kann hilfreich sein, da er nachweislich ein individuelles Patientenmanagement ermöglicht.

Geänderte Empfehlung 8

Vor der RIT sollte 2 Wochen lang eine jodarme Diät eingehalten werden. Jodhaltige Medikamente sollten vermieden werden.



Publication History

Article published online:
17 March 2022

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