Radioiodine for remnant ablation and therapy of metastatic disease

Radioiodine is considered an effective and low-risk therapy modality of advanced differentiated thyroid cancer. For patients without lymph-node or distant metastases and low stages of the primary tumor, debate is ongoing about the necessity of thyroid remnant tissue ablation in an adjuvant setting. On the basis of evidence from retrospective studies, and until results of ongoing controlled prospective randomized trials become available, I-131 ablation of remnant thyroid tissue in patients with primary tumors >1 cm is advisable. For thyroid remnant ablation, individual dosimetry is not obligatory. By contrast, the effectiveness of 131I therapy of locally advanced and/or metastatic disease can be improved by individual dosimetry. For practical reasons, an approach delivering the maximal possible radiation dose to the tumor without exceeding a critical blood dose of approximately 2 Gy seems advantageous. The availability of recombinant human TSH (rhTSH) has improved the quality of life of patients and reduces the radiation exposure of healthy nonthyroid tissue compared with TSH stimulation through levothyroxine withdrawal. In patients with distant metastases, rhTSH stimulation is possible only in off-label use, from which especially elderly and frail patients may benefit, as they most severely suffer from hypothyroidism caused by thyroid hormone withdrawal.