Standard-of-Care Treatment for Patients with Advanced RAI-R-DTC
Clinical insights on the standard-of-care treatment of patients with advanced RAI-R-DTC, the NCCN guideline recommendations, and challenges encountered in treatment.
Case: A 43-Year-Old Man with RAI-R-DTC
Initial presentation and initial treatment:
- A 43-year-old man presents with fatigue, neck pain and dysphagia and was diagnosed with papillary thyroid carcinoma 10 years ago
- Following a total thyroidectomy, he underwent multiple rounds of radioactive ablation therapy.
- Initial response was positive with undetectable thyroid globulin levels and negative imaging
- PMH: Hyperlipidemia; Hypertension; Diabetes (controlled with medications)
- SH: lives with his wife and 2 teenage children; non-smoker and drinks alcohol occasionally
- PE: appears fatigued with a palpable thyroid nodule in the left lobe
- Neck examination: palpable mass in the left neck, and cervical lymphadenopathy
Clinical workup
- Labs: WNL
- Neck ultrasound: Identifies a large, irregular mass in the left thyroid bed with invasion into surrounding structures.
- CT of the neck and chest revealed neck mass along with multiple pulmonary nodules, largest 2cm x 1.5cm
- TSH: Within normal limits
- Thyroglobulin levels: Markedly elevated
- Radioactive iodine scan: Confirms radioiodine refractory disease with widespread involvement of cervical lymph nodes and distant metastases.
- Needle biopsy was performed which confirmed Papillary thyroid cancer. Next-generation sequencing was negative for mutations, rearrangements
Subsequent treatment and follow-up
- Lenvatinib 24mg po qd was initiated
This is a video synopsis/summary of a Case-Based Peer Perspectives featuring Marcia S. Brose, MD, PhD.
Brose discusses the standard of care for patients with radioiodine-refractory differentiated thyroid cancer (RAI-R-DTC) in the first-line setting. Both sorafenib and lenvatinib are FDA-approved and considered the standard of care for these patients, as supported by the National Comprehensive Cancer Network (NCCN) guidelines. However, for patients harboring RET or NTRK fusions, the standard of care may be changing. In the presented case, the patient did not have these fusions, so sorafenib and lenvatinib remain the standard of care. Although over 50% of patients may have a BRAF mutation, the efficacy of BRAF inhibitors is not superior to lenvatinib, and they are typically used in later lines of therapy.
Challenges in managing RAI-R-DTC include the development of resistance to systemic therapies and adverse events. To prolong the benefit of systemic therapy, local therapy (surgery or radiation) can be used to treat a single progressing lesion. Physicians experienced in managing the adverse events of sorafenib and lenvatinib should treat these patients to ensure optimal outcomes and avoid unnecessary dose reductions or treatment discontinuation.
Video synopsis is AI-generated and reviewed by Targeted Oncology™ editorial staff.
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