DTC Treatment: Safety Profiles for Sorafenib and Lenvatinib
Lori Wirth, MD, discusses the safety profiles of sorafenib and lenvatinib and provides clinical insights on managing or mitigating adverse effects.
Case: A 64-Year-Old Woman with DTC
Initial presentation
- A 64-year-old woman presents with a painless “lump on her neck” with occasional swelling. She states she noticed this just a few days after returning from vacation.
- PMH: Hyperlipidemia managed with medication; COPD
- PE: palpable, non-tender solitary right-of-the midline neck mass; mobile supraclavicular mass on the same side; otherwise unremarkable
Clinical workup and initial treatment
- Labs: TSH WNL
- Ultrasound of the neck revealed a 3.3-cm suspicious right mass in the lobe of the thyroid; 2 suspicious supraclavicular lymph nodes (LNs), largest 2.0 cm in size.
- Ultrasound-guided FNAB of the thyroid mass and the largest LN confirmed papillary thyroid carcinoma.
- Patient underwent total thyroidectomy with central compartment node dissection and right selective neck dissection.
- Pathology: 3.0-cm papillary thyroid cancer, columnar cell variant; 4/14 lateral positive LN, 3/3 central positive LN
- Largest lateral node was 2.2 cm with no extra-nodal extension
- Margins were negative
- Microscopic extrathyroidal extension present
- Probable stage II; T2N1bM0 papillary thyroid cancer
Subsequent treatment and follow-up
- She was treated with radioactive iodine 150 millicuries
- Whole body scan showed uptake in the neck, consistent with remnant thyroid tissue
- She was started on levothyroxine suppression therapy
- Follow-up at 6 months
- TSH 0.1 µU/mL, thyroglobulin 24 ng/mL (negative anti-thyroglobulin antibodies)
- Chest CT scan showed 8 small bilateral lung nodules only several mm in size
- Next-generation sequencing was negative for mutations, rearrangements
- Follow-up CT chest scan and blood tests 3 months later
- Thyroglobulin increased
- Lung nodules had increased by up to 1 cm in size
- Lenvatinib 24mg po qd was initiated
This is a video synopsis/summary of a Case-Based Peer Perspective featuring Lori Wirth, MD.
Wirth compares the adverse event profiles of sorafenib and lenvatinib, noting their similarity as VEGFR multikinase inhibitors. Both drugs are associated with VEGFR-related adverse reactions such as hand-foot syndrome, hypertension, diarrhea, anorexia, weight loss, and fatigue. There is a slightly increased risk of thromboembolic disease and fistula formation with both agents. Sorafenib tends to cause more hand-foot syndrome and rash compared with lenvatinib, while lenvatinib is associated with more hypertension.
Management strategies for these adverse reactions include dose holds, dose reductions, and supportive care. For hypertension, Wirth emphasizes the importance of blood pressure control prior to starting therapy, home monitoring, and prompt intervention with antihypertensive agents. Involving a cardiologist can be helpful for refractory cases. Hand-foot syndrome can be managed with good skin care, keratolytics, and urea creams, with dermatologist input for severe cases. Dietary modifications, nutritional supplements, and consultation with dietitians can help manage chronic diarrhea.
Wirth notes that sorafenib might be the preferred first-line choice over lenvatinib for patients with difficult-to-control hypertension at baseline, as lenvatinib seems to precipitate more refractory hypertension.
Video synopsis is AI-generated and reviewed by Targeted Oncology® editorial staff.
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