2019 European Thyroid Association Guidelines for the Treatment and Follow-Up of Advanced Radioiodine-Refractory Thyroid Cancer

Abstract

The vast majority of thyroid cancers of follicular origin (TC) have a very favourable outcome, but 5–10% of cases will develop metastatic disease. Around 60–70% of this subset, hence less than 5% of all patients with TC, will become radioiodine refractory (RAI-R), with a significant negative impact on prognosis and a mean life expectancy of 3–5 years. Since no European expert consensus or guidance for this challenging condition is currently available, a task force of TC experts was nominated by the European Thyroid Association (ETA) to prepare this document based on the principles of clinical evidence. The task force started to work in September 2018 and after several revision rounds, prepared a list of recommendations to support the treatment and follow-up of patients with advanced TC. Criteria for advanced RAI-R TC were proposed, and the most appropriate diagnostic tools and the local, systemic and palliative treatments are described. Systemic therapy with multikinase inhibitors is fully discussed, including recommendations on how to start it and at which dosage, on the duration of treatment, and on the management of side effects. The appropriate relationship between the specialist and the patient/family as well as ethical issues are covered. Based on the available studies and on personal experience, the experts provided 39 recommendations aimed to improve the management of advanced RAI-R TCs. Above all of them is the indication to treat and follow these patients in a specialized setting which allows the interaction between several specialists in a multidisciplinary team.

Left Supraclavicular Lymph Node Metastasis from Ovarian Cancer Associated with Papillary Thyroid Microcarcinoma, a Confusing Pathology-Essential Role of Functional Imaging

“…The thyroid ultrasound description of left thyroid nodule leads to a classification corresponding to TIRADS 3 [14]; the greater nodule dimension was 6.9 mm (< 1 cm), without significant suspicious signs of malignancy (ex. microcalcification, internal vascularization), the fine-needle aspiration biopsy (FNAB) was indicated as a diagnostic option, according to the American Thyroid Association (ATA) guidelines and European Thyroid Association (ETA) guidelines [9,10]; the procedure was performed and the result, according to the Bethesda System for Reporting Thyroid Cytopathology [15], was Thy 5-suspicious for malignancy. The FNAB result of Thy 5-suspicious for malignancy-in the thyroid nodule and the ultrasound characteristics of the lymph node (round shape, highly hilar and peripheral vascularity, predominantly hypoechoic, not hyperechoic, and without calcification) made us think of an origin of the lymph node metastasis other than the thyroid gland.…”

“…Papillary thyroid cancer (PTC) is the most common thyroid malignancy [9][10][11] and is defined as a malignant epithelial tumor. Papillary thyroid microcarcinoma (MPTC) is a PTC with a maximum diameter of < 1 cm.…”

Non-Coding RNAs: Uncharted Mediators of Thyroid Cancer Pathogenesis

“…Upon thyroid cancer diagnosis, the patients are treated by surgical thyroidectomy (13). Patients with more advanced thyroid cancers with higher risk of recurrent or persistent disease undergo adjuvant radioactive iodine (RAI) therapy, while patients with RAI-refractory differentiated thyroid cancer with progressive, symptomatic and metastatic disease, not treatable with local therapy, undergo systemic therapy, including targeted therapy and chemotherapy (12). The chemotherapy drugs commonly used to treat thyroid cancer, in particular, the aggressive medullary and anaplastic thyroid malignancies are Dacarbazine, Vincristine, Cyclophosphamide, Doxorubicin, Streptozocin, Fluorouracil, Paclitaxel, Docetaxel and Carboplatin (193)(194)(195)(196)(197).…”

“…The main measures to detect thyroid cancer are ultrasound, radioiodine scanning and Fine-Needle Aspiration (FNA) biopsy (12), and the treatment for thyroid cancer is surgical thyroidectomy (13). Postsurgery, other therapeutic strategies including radioactive iodine therapy, and systemic therapies might be incorporated into the treatment regime for patients with high risk of recurrent or persistent disease (14).…”

Preoperative Factors Associated with Extrathyroidal Extension in Papillary Thyroid Cancer

“…Standard treatment consists of surgery with or without radioactive iodine (RAI) therapy. For patients who have RAI-refractory thyroid cancer, the management options are limited [2]. A few clinicopathologic factors have been identified to be associated with overall survival (OS) in PTC patients [3].…”