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Post-operative stimulated thyroglobulin and neck ultrasound as personalized criteria for risk stratification and radioactive iodine selection in low- and intermediate-risk papillary thyroid cancer

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Abstract

The purpose of this study was to demonstrate the utility of a personalized risk stratification and radioactive iodine (RAI) selection protocol (PRSP) using post-operative stimulated thyroglobulin (Stim-Tg) and neck ultrasound in low- and intermediate-risk papillary thyroid carcinoma (PTC) patients. Patients with PTC tumors ≥1 cm were prospectively followed after total thyroidectomy and selective therapeutic central compartment neck dissection. Low/intermediate risk was defined as PTC confined to the thyroid or central (level VI) lymph nodes. Stim-Tg and neck ultrasound were performed approximately 3 months after surgery and used to guide RAI selection. Patients with Stim-Tg < 1 µg/L did not receive RAI, while those with Stim-Tg >5 µg/L routinely did. Those with Stim-Tg 1–5 µg/L received RAI on the basis of several clinical risk factors. Patients were followed for >6 years with serial neck ultrasound and basal/stimulated thyroglobulin. Among the 129 patients, 84 (65 %) had undetectable Stim-Tg after initial surgery, 40 (31 %) had Stim-Tg of 1–5 µg/L, and 5 (4 %) had Stim-Tg >5 µg/L. RAI was administered to 8 (20 %) patients with Stim-Tg 1–5 µg/L and 5 (100 %) with Stim-Tg >5 µg/L. Using this approach, RAI therapy was avoided in 17/20 (85 %) patients with tumors >4 cm, in 72/81 (89 %) patients older than 45 years, and in 6/9 (67 %) patients with central lymph node involvement. To date, 116 (90 %) patients in this cohort have not received RAI therapy with no evidence of residual/recurrent disease, whereas among the 13 patients who received RAI, 1 (8 %) had pathologic residual/recurrence disease. Using the proposed PRSP, RAI can be avoided in the majority of low/intermediate-risk PTC patients. Moreover, traditional risk factors considered to favor RAI treatment were not always concordant with the PRSP and may lead to overtreatment.

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Acknowledgments

This study was supported in part by unrestricted educational grants from Abbott Laboratories Limited Canada; the Da Vinci Gala Fundraiser; the George Knudson Oakdale Pro-Am Charity Golf Tournament; the Department of Medicine Research Fund, Mount Sinai Hospital; the Mount Sinai Hospital Foundation of Toronto; and the Alex and Simona Shnaider Research Chair in Thyroid Oncology.

Conflict of interest

PGW receives consulting fees from Genzyme Canada, a Sanofi company. SO, FS, JLF, AV, and IJW have no relevant disclosures of interest.

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Authors and Affiliations

  1. Endocrine Division, Department of Medicine, Joseph and Mildred Sonshine Family Centre for Head & Neck Diseases, Mount Sinai Hospital, 413-7, 600 University Avenue, Toronto, ON, M5G 1X5, Canada

    Steven Orlov, Farnaz Salari, Lawrence Kashat & Paul G. Walfish

  2. University of Toronto, School of Medicine, 1 King’s College Circle, Room 2109, Toronto, ON, M5S 1A8, Canada

    Steven Orlov, Farnaz Salari, Lawrence Kashat, Jeremy L. Freeman, Allan Vescan, Ian J. Witterick & Paul G. Walfish

  3. Otolaryngology-Head and Neck Surgery Program, Mount Sinai Hospital, 413-9, 600 University Avenue, Toronto, ON, M5G 1X5, Canada

    Jeremy L. Freeman, Allan Vescan, Ian J. Witterick & Paul G. Walfish

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  1. Steven Orlov
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Correspondence to Paul G. Walfish.

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Orlov, S., Salari, F., Kashat, L. et al. Post-operative stimulated thyroglobulin and neck ultrasound as personalized criteria for risk stratification and radioactive iodine selection in low- and intermediate-risk papillary thyroid cancer. Endocrine 50, 130–137 (2015). https://doi.org/10.1007/s12020-015-0575-0

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  • DOI: https://doi.org/10.1007/s12020-015-0575-0

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