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thyroid carcinoma does not respond to 131I therapy and is resistant to chemotherapy Patients with thyroid MALT lymphomas have a low risk of recurrence after simple thyroidectomy Patients with other thyroid lymphomas are best treated with external radiation therapy; chemotherapy is added for extensive lymphoma Patients with systemic lymphomas involving the thyroid are usually treated with chemotherapy Patients with medullary thyroid carcinoma are treated surgically; repeated neck dissections are often required over time Medullary thyroid carcinomas do not respond to 131I therapy Medullary thyroid carcinoma is generally resistant to chemotherapy, although there have been encouraging preliminary results from a clinical trial with a second-generation inhibitor of vascular endothelial growth factor receptors (VEGFR) Patients with medullary thyroid carcinoma are advised to have genetic testing for ret protooncogene mutations Patients who are discovered to have a germline mutation may require surveillance for other manifestations of MEN; genetic testing of first-degree relatives is also advisable It is advisable that children with a ret protooncogene mutation have a prophylactic total thyroidectomy, ideally by age 6 years (MEN 2A) or at age 6 months (MEN 2B) Medullary thyroid carcinoma does not take up 131I
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Recombinant human thyrotropin (rhTSH) injections do not stimulate RAI uptake sufficiently to prepare patients with stage II IV cancer for 131I ablative therapy of thyroid cancer Also, patients receiving thyrotropin injections are euthyroid and have a high renal clearance of RAI, reducing the effectiveness of 131I therapy However, many centers are using rhTSH to stimulate 131I uptake for thyroid remnant ablation in patients with stage I cancer Such patients can also have T4 withdrawn for 1 week before the rhTSH and 131I therapy to allow endogenous TSH levels to rise and provide additional stimulation of RAI uptake Thyrotropin stimulation is also useful for patients with functional metastases whose serum TSH is always suppressed Patients must follow a low-iodine diet for 2 weeks before 131 I therapy Just before therapy, serum is obtained for measurement of TSH (to make certain it is > 30 mcU/mL), thyroglobulin, and hCG (in all reproductive-age women) Pregnant women may not receive RAI therapy Women are advised to avoid pregnancy for at least 4 months following 131I therapy Men have been found to have abnormal spermatozoa for up to 6 months following 131I therapy and are advised to use contraceptive methods during that time Sodium 131I, 30 50 mCi (1110 1850 MBq), is administered orally to patients with an original papillary or follicular carcinoma 15 cm in diameter and also to patients having persistent RAI uptake in the thyroid bed following near-total thyroidectomy Patients with extrathyroidal uptake from metastatic disease are given larger doses of about 125 150 mCi (5550 MBq) 131I orally in the hospital A posttherapy whole-body scan performed 1 week after 131I treatment will often detect metastases that were not visible on pretreatment scans Four days following 131I therapy, Cytomel is resumed at a dose of 25 mcg orally twice daily for 1 week, reduced to 125 mcg twice daily for the next week At the same time, T4 is resumed and continued at a full thyroid replacement dose About 35% of patients with metastatic differentiated thyroid carcinoma have poor uptake of RAI into metastases Lithium inhibits the release of 131I from differentiated thyroid cancer and may increase the absorbed radiation dose; however, prospective treatment trials are lacking 131 I therapy in doses over 100 mCi (3799 MBq) can cause gastritis, temporary oligospermia, sialadenitis, and xerostomia RAI therapy can cause neurologic decompensation in patients with brain metastases; it is advisable to treat such patients with prednisone 30 40 mg orally daily for several days before and after 131I therapy Cumulative doses of 131I over 500 mCi can cause infertility, pancytopenia (4%), and leukemia (03%) The kidneys excrete RAI To reduce the risk of radiation-induced side effects, patients receiving dialysis for renal failure require a dosage reduction to only 20% of the usual dose of 131I
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