Iodine Status and Thyroid Function of Vegans versus Non-Vegan Adults
131 IODINE TREATMENT FOR THYROID CANCER IN CHILDREN
Transcript of 131 IODINE TREATMENT FOR THYROID CANCER IN CHILDREN
131 – IODINE TREATMENT
FOR THYROID CANCER
IN CHILDREN
Jasna Mihailović, MD, PhD, Prof
Head, Department of Nuclear Medicine
Oncology Institute of Vojvodina
Sremska Kamenica, Serbia
Speaker Name: Jasna Mihailovic
I have no financial interests or relationships to disclose with regard to the
subject matter of this presentation.
Declaration of
Financial Interests or Relationships
Juvenile DTC - Introduction
Juvenile differentiated thyroid carcinoma (JDTC) is a rare
malignancy (0.5%–3% of all malignant tumors in
childhood).
DTC incidence of 7% and 10%, is reported in prepubertal
and adolescent period, respectively.
The Serbian Cancer Registry: 44 newly diagnosed cases of
DTC in ≤19 y old patients (1999-2012); Female-to-male
ratio = 3.9:1.
Juvenile DTC - Introduction
Aggressive initial presentation - involvement of cervical
lymph nodes and frequently distal metastases.
Usually, juvenile DTC has a good clinical outcome. 98% of
disease-specific survival after 30 years following the initial
surgery (Hay 2010).
High recurrence rate.
Juvenile DTC
Recurrent disease - Prognostic factors
1. Initial treatment - Extent of surgery and RAI
Less radical primary surgery increases relapse rate.
Ten times higher recurrence (range 2.3-39.1) among
children who undergo less extensive surgery (Jarzab 2000).
Recurrence rate obtained after hemithyroidectomy was
higher than after TTx (38% vs.7.5%, respectively)
(Popovitzer 2006).
Patients postoperatively treated with RAI show lower risk for
recurrence that patients who did not receive ablation
(Jarzab 2000, Chow 2004, Mihailovic 2014).
Juvenile DTC
Recurrent disease - Prognostic factors
2. Age
Not a significant factor (Handkiewicz-Junak 2007, Palmer 2005).
Age at diagnosis - significant patient-related factor in
univariate anlaysis (Jarzab 2000, Mihailovic 2014).
Higher risk of relapse in younger children ( ≤10 yr old) (Mazzaferri 1994, Jarzab 2000, Mihailovic 2014).
3. Tumor multifocality
Patients with multifocal tumors - higher recurrence
rate than those with unifocal tumors (Lin 2009, Mihailovic 2014).
Juvenile DTC - Treatment
Usually treated the same way as in adults.
Recently, in 2015, the ATA Guidelines Task Force on
Pediatric Thyroid Cancer released Management
Guidelines for Children with Thyroid Nodules and
Differentiated Thyroid Cancer (Thyroid 2015).
Juvenile DTC - Treatment
RAI activity:
Body weight (1.85 – 7.4 MBq/kg)
Patient's age
1/3 adult activity to 5-yr old
1/2 adult activity to 10-yr old
5/6 adult activity to 15-yr old
24h-RAIU and by BW
<5% uptake to 50 MBq/kg
5-10% uptake to 25 MBq/kg
10-20% uptake to 15 MBq/kg
Juvenile DTC - Treatment
I-131 activity for ablation: longer life expectancy, higher
sensitivity to possible complications after treatment,
smaller body and organ size.
In patients with extensive lung metastases, there is
concern about high radiation absorbed dose to the
lungs and pulmonary fibrosis.
DOSIMETRY/ REDUCED I-131 ACTIVITY!
There are no effects on subsequent fertility and
pregnancy outcome and no secondary malignancies
(La Quaglia 1988, Chow 2004, Mihailovic 2014).
SERBIAN EXPERIENCE
Mihailović J, et al. Recurrent Disease in Juvenile Differentiated Thyroid Carcinoma:
Prognostic Factors, Treatments, and Outcomes. J Nucl Med 2014.
Period = January 1977 - December 2012
1,502 DTC patients were treated with I-131
(53 JDTC patients)
51 patients without a history of prior radiation were
retrospectively reviewed (32 girls and 19 boys)
(mean age, 16.5 yrs; range, 7–20 yrs)
INITIAL TREATMENT
Surgical treatment differed among hospitals.
RAI Ablation
The Oncology Institute of Vojvodina was the only facility
in Serbia for RAI through 2006.
RAI ablation was administered 4 weeks after withdrawal
of L-thyroxine (T4) therapy.
Whole-body or blood dosimetry calculations were not
performed.
In prepubertal children = BW (50–100 MBq/kg)
After puberty = 3.7-5.6 GBq
(3.7 GBq was used in N0M0; 5.6 GBq in N1M0/N1M1)
Response to the initial treatment
RESULTS
Recurrence developed in 11/51 (21.6%) patients.
The median appearance time is 52 mo (range, 12–180
mo).
Prognostic factors with no influence to the recurrence:
sex, nodal metastases at presentation, distal metastases at
presentation, histologic type of the tumor, T stage, and
clinical stage (P = 0.180, P = 0.786, P = 0.796, P = 0.944,
P = 0.352, and P = 0.729, respectively).
Probability of recurrence
5 years = 16.7%
10 years = 22.3%
15, 25 years = 33.3%
P = 0.0001
Influence of type of the initial treatment
Influence of patient’s age at diagnosis
P = 0.001
Influence of tumor multifocality
P = 0.011
RESULTS - Recurrence
Localization
Thyroid bed = 1 patient
Cervical LN = 5 patients
Distant sites (lungs) = 3 patients
Combined (lungs and brain; cervical LN and lungs) = 2
patients
Time of appearance
1 patient = after 4 and 12 years
1 patient = after 7, 22, and almost 25 years
TREATMENT OF RECURRENT
DISEASE
CASE 1
14-years old girl; after primary surgery+EBRT (115 Gy)+ 4xRAI;
I-131 WBS PA; TSH, 40mU/l; Tgb, 850μg/L
two years later, I-131 WBS AP; TSH, 45mU/l; Tgb, 13μg/L
FINAL OUTCOME
During the FU 25/36 patients with initial CR did not relapse;
1 patient with CR died from another cause of death.
14 patients with initial PR were retreated; outcome:12 patients = CR,
1 patient with PD = CR.
11 female patients (CA, 3.7–40 GBq) ultimately had children
(8 women delivered 2 children, and 3 women had 1 child)
CONCLUSION
TTx followed by RAI appears to be an appropriate initial
treatment.
Younger age at diagnosis, tumor multifocality,
insufficient primary surgery, and lack of radioiodine
ablation are risk factors for recurrent disease in JDTC.
Recurrent disease should be treated with surgery or
radioiodine treatment until remission.
Both initial treatment with radioiodine and retreatment
with radioiodine are safe, with no adverse effects on
fertility or secondary malignancy.