Standard of Care Treatment for Patients With Advanced RAI-Refractory DTC
An overview of the standard of care treatment for patients with advanced radioiodine-refractory differentiated thyroid cancer.
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 discusses the National Comprehensive Cancer Network guidelines for patients with progressive radioactive iodine (RAI)–refractory differentiated thyroid cancer (DTC). The guidelines recommend molecular diagnostics whenever possible before initiating therapy due to the availability of gene-specific first-line treatment options, such as larotrectinib or entrectinib for NTRK fusion–positive patients and selpercatinib or pralsetinib for RET fusion–positive disease. Lenvatinib has a preferred category 1 recommendation for progressive RAI-refractory DTC without oncogenic gene fusions, while sorafenib also has a category 1 recommendation.
One challenge in initiating treatment is determining the appropriate timing. Asymptomatic patients with a low disease burden and slow growth may not require immediate therapy, and ongoing disease monitoring and thyroid-stimulating hormone suppression may be the most appropriate approach. However, patients with rapidly progressive RAI-refractory DTC or those likely to develop disease progression symptoms should initiate treatment. Subset analyses from the SELECT trial suggest that symptomatic patients do not respond to treatment, emphasizing the importance of not waiting until symptoms develop before starting therapy.
Video synopsis is AI-generated and reviewed by Targeted Oncology® editorial staff.
Anticipating Novel Options for the RAI-Refractory DTC Armamentarium
May 15th 2023In season 4, episode 6 of Targeted Talks, Warren Swegal, MD, takes a multidisciplinary look at the RAI-refractory differentiated thyroid cancer treatment landscape, including the research behind 2 promising systemic therapy options.
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