Radioiodine Therapy: Review of the Empiric Fixed Dose Approaches and Their Selective Applications

Mi Park Jung

doi:10.11106/jkta.2013.6.1.34

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Jung: Radioiodine Therapy: Review of the Empiric Fixed Dose Approaches and Their Selective Applications

Original Article

J Korean Thyroid Assoc 2013;6(1):34-42.

Published online: 3 May 2013

DOI: https://doi.org/10.11106/jkta.2013.6.1.34

Radioiodine Therapy: Review of the Empiric Fixed Dose Approaches and Their Selective Applications

Mi Park Jung

Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea

Address reprint requests to Jung Mi Park, MD, PhD, Department of Nuclear Medicine, Soonchunhyang University Bucheon Hospital, 170, Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea Tel: 82-32-621-588, Fax: 82-32-621-5749, E-mail: jmipark@schmc.ac.kr

Received 2 February 2013 Accepted 2 February 2013

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Empiric fixed dose approach is commonly adopted in the radioiodine therapy (RIT) for thyroid cancer, and considered to be a reasonably safe, simple, and easy practice. Recent clinical guidelines and articles suggested that RIT should be more selectively applied, based on risk stratification and individual treatment. However, there was no specific dose of RIT for each risk group. Application of empiric fixed dose can be needed, based on the guidelines, to improve therapeutic prognosis and radiation safety in the selected patients. In Korea, for the low risk group according to some prognostic factors, such as histology and genetic mutation, RIT can be selected, preferably using higher dose. To minimize any side effects, on the other hand, radioiodine dose can be decreased and optimized for patient's body weight, age, and kidney function. For the advanced thyroid cancer, higher fixed dose of radioiodine could be administered to improve survival and to reduce recurrence.

Keywords: Thyroid neoplasm, Radioiodine therapy, Fixed dose

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Table 1.

TNM classification system for differentiated thyroid cancer and recommendation of radioiodine therapy

TNM	Description	Radioiodine therapy of guideline
TNM	Description	ATA 2009	BTA 2007
T1	Tumor ≤1 cm, intra-thyroidal or microscopic multifocal	No	Probable yes (multifocal tumor, or with unfavorable histology)
	1 cm < tumor ≤ 2 cm	Selective use*	Probable yes
T2	2 cm < tumor ≤ 4 cm	Selective use*	Probable yes
T3	Tumor > 4 cm	Yes	Yes
	Any size, any age, minimal extrathyroidal extension	Selective use*	Yes
T4	Any size with gross extrathyroidal extension	Yes	Yes
N1		Selective use*	Yes (≥10 LNs or ≥3 with extracapsular spread)
M1		Yes	Yes
Etc.			Probable yes (LN status not assessed at surgery, or less than total thyroidectomy)

ATA: American Thyroid Association, BTA: British Thyroid Association. *Selected patients in this subgroup with higher risk histologic features (such as tall cell, columnar, insular, and solid variants, as well as poorly differentiated thyroid cancer) in combination with age, tumor size, lymph node, individual histology may benefit from RAI ablation

Table 2.

Comparison of ablation rate after initial radioidine therapy in thyroid cancer

Studies	Year	No of cases	Stages	% of stage III or IV	PTC (%)	RI doses (mCi)	Ablation rate (%)	Definition of ablation (stimulated Tg)
Schlumberger et al.²¹⁾	2012	684	AnyT1–T2N0		89.3-92.5	30, 100	92.3, 95.2	< 2 ng/mL
Mallick et al.²²⁾	2012	421*	Excluding T4, M	T3, T4: 23		30, 100	85.0, 88.9	< 1 ng/mL
Kukulska et al.²³⁾	2010	309	Excluding M	T4, N1: 5.8	85.8	30, 60, 100	78.0, 86.6, 88.8	< 10 ng/mL
Hu et al.²⁴⁾	2004	245	Excluding M	III: 26	95.0	75-100	72.2 (44.4% for dx scan pre-RIT)	No uptake
Bernier et al.²⁵⁾	2005	407	Including M		81.0	100	87.5	< 2 ng/mL
Verburg et al.²⁶⁾	2005	180	Including M		68.3	100, 150, 200	61.0	Undetectable
Nam et al.²⁷⁾	2009	85	Excluding M	44.7	95.3	100, 150	75.3	< 2 ng/mL
Lee et al.²⁸⁾	2007	81	Excluding M	39.5	87.7	100-200	82.7	Undetectable
Kim et al.²⁹⁾	2011	1024	Excluding M	57.9	95.4	30, 80, 150	81.7, 89.5, 94.8	< 2 ng/mL
Lim et al.³⁰⁾	2012	173	Including M	>73		100-200	53.8^ℸ	< 2 ng/mL

All patients had a total or near total thyroidectomy before ablation. Dx: diagnostic, PTC: papillary thyroid cancer, RI: radioiodine, RIT: radioiodine therapy. *Total thyroidectomy was done in 98%. ^†rhTHS (n=39), THW (n=46) was used, all data was summed. ^ℸRepeated radioiodine therapy

Table 3.

Complications according to the cumulative dose of I-131

Complication as cumulative dose	100-200 mCi	500–800 mCi	> 1000 mCi
Transient change in taste, absence of taste Sialadenitis Male infertility Female infertility Bone marrow effect Secondary malignancy Leukemia Solid cancer	16–27%^39,48) Acute 33%, persistent 42% 1 year later^38,39,48) Prevention: IV amifostine,^40-43) pilocarpine,^39,41) massage Rare, transient impairment of gonadal function⁵²⁾ Rare Rare Rare	More common More common Recommend sperm banking^39,52) Rare,³⁹⁾ transient amenorrhea 17% (230–1590 mCi)⁵¹⁾ Not uncommon,³⁹⁾ Not uncommon,³⁹⁾ ≤2 Gy: minimal transient effect³⁹⁾ AR: 0.8/GBq/10⁵ person–years,⁵⁰⁾ RR: 2.5⁴⁹⁾ AR: 14.4/GBq/10⁵ person–years,⁵⁰⁾ RR: 1.19⁴⁹⁾

AR: absolute risk, RR: relative risk

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