Treatment Sequencing and Advice for Community Oncologists Treating RAI-R-DTC
Marcia S. Brose, MD, PhD, discusses treatment sequencing practices and offers advice for community oncologists treating patients with RAI-R-DTC.
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 sequencing of treatments for patients with radioiodine-refractory differentiated thyroid cancer (RAI-R-DTC). In the first-line setting, sorafenib and lenvatinib are approved, while cabozantinib is approved for the second-line setting. Brose typically uses cabozantinib in the second-line setting, as it is active regardless of prior treatment with sorafenib or lenvatinib. She rarely moves to another class of drugs, such as BRAF inhibitors, unless the patient has a BRAF mutation and has exhausted lenvatinib and cabozantinib.
Sorafenib may be used in the first-line setting for patients with fistulas or severe hypertension, as it has fewer blood pressure-related adverse effects compared to lenvatinib. Brose emphasizes the importance of having experienced providers treat these patients, as they will be on oral therapy for years and may encounter various adverse events over time. Close follow-up at 1, 2, and 4 weeks, and then monthly for at least 6 months, is crucial. Providers must be dedicated to helping patients manage adverse effects and maintain a good quality of life, as these patients often want to live a full life and work full-time while on long-term treatment.
Video synopsis is AI-generated and reviewed by Targeted Oncology™ editorial staff.
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