Personalized management of differentiated thyroid cancer in real life – practical guidance from a multidisciplinary panel of experts

Abstract

Purpose The standard of care for differentiated thyroid carcinoma (DTC) includes surgery, risk-adapted postoperative radioiodine therapy (RaIT), individualized thyroid hormone therapy, and follow-up for detection of patients with persistent or recurrent disease. In 2019, the nine Martinique Principles for managing thyroid cancer were developed by the American Thyroid Association, European Association of Nuclear Medicine, Society of Nuclear Medicine and Molecular Imaging, and European Thyroid Association. In this review, we present our clinical practice recommendations with regard to implementing these principles in the diagnosis, treatment, and long-term follow-up of patients with DTC. Methods A multidisciplinary panel of five thyroid cancer experts addressed the implementation of the Martinique Principles in routine clinical practice based on clinical experience and evidence from the literature. Results We provide a suggested approach for the assessment and diagnosis of DTC in routine clinical practice, including the use of neck ultrasound, measurement of serum thyroid-stimulating hormone and calcitonin, fine-needle aspiration, cytology, and molecular imaging. Recommendations for the use of surgery (lobectomy vs. total thyroidectomy) and postoperative RaIT are also provided. Long-term follow-up with neck ultrasound and measurement of serum anti-thyroglobulin antibody and basal/stimulated thyroglobulin is standard, with 123/131I radioiodine diagnostic whole-body scans and 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography suggested in selected patients. Management of metastatic DTC should involve a multidisciplinary team. Conclusions In routine clinical practice, the Martinique Principles should be implemented in order to optimize clinical management/outcomes of patients with DTC.

Intratumoral Heterogeneity in Differentiated Thyroid Tumors: An Intriguing Reappraisal in the Era of Personalized Medicine

“…Recent studies based on genetic analysis of thyroid tumors have brought several intriguing therapeutical personalized options for DTCs [ 120 ]. This innovative vision in which particularly targeted therapies based on specific diagnostic tests has been defined as “theranostics”, in order to provide a transition from conventional to a contemporary personalized medicine [ 121 ]. The first theranostic agent has been considered as the radioiodine treatment widely used for the management of DTC.…”

“…The first theranostic agent has been considered as the radioiodine treatment widely used for the management of DTC. Nevertheless, about 65% of the patients with advanced thyroid disease may became radioiodine-refractory related to the sodium/iodide symporter (NIS) [ 120 , 121 ]. Therefore, the targeted therapy of DTC should be connected to the genetic and epigenetic alterations and signaling pathways.…”

“…Therefore, the targeted therapy of DTC should be connected to the genetic and epigenetic alterations and signaling pathways. In detail, PPARγ agonists, HDAC inhibitors, PI3K/AKT inhibitors and MEK/ERK inhibitors, have been recommended for NIS over-expression and have caused improved iodine uptake in thyroid cancers [ 121 ]. Moreover, it was shown that Dabrafenib represents the selective inhibitor of mutated forms of BRAF and it can realize the radioiodine uptake in metastatic PTC BRAF V600E -mutant iodine-refractory patients.…”

“…Moreover, it was shown that Dabrafenib represents the selective inhibitor of mutated forms of BRAF and it can realize the radioiodine uptake in metastatic PTC BRAF V600E -mutant iodine-refractory patients. Similarly, some molecular markers such as p53 , PIK3CA , CTNNB1 and AKT1 may be considered indicators for an aggressive behavior of DTCs [ 121 ]. Furthermore, since fine needle aspiration cytology (FNAC) has been considered the commonly utilized morphological test, the molecular profiling may improve the diagnostic accuracy mainly in indeterminate or gray zone, furtherly supporting a personalized treatment for DTCs [ 122 ].…”

The role of Tg kinetics in predicting 2-[18F]-FDG PET/CT results and overall survival in patients affected by differentiated thyroid carcinoma with detectable Tg and negative 131I-scan

“…Excluding low-risk disease, the baseline treatment of DTC consists of thyroidectomy followed by postoperative risk-adapted sodium iodide ([ 131 I]) therapy if indicated [1,3]. This approach leads to an excellent response in the majority [1,4], often even 6-12 months after primary therapy [5]. However, a long-term active follow-up is mandatory because DTC is a dynamic disease and the possibility to have persistent disease or relapse is not uncommon, especially in intermediate and high risk patients [6].…”