ESSENTIALS OF THYROID CANCER MANAGEMENT

ESSENTIALS OF THYROID

CANCER MANAGEMENT

ESSENTIALS OF THYROID CANCER MANAGEMENT

Edited by

ROBERT J. AMDUR, MD

Professor, Department of Radiation Oncology University of Florida College of Medicine Gainesville, Florida USA

ERNEST L. MAZZAFERRI, MD, MACP

Professor, Department of Medicine University of Florida College of Medicine Gainesville, Florida USA

Emeritus Professor and Chairman of Internal Medicine Ohio State University

Columbus, Ohio USA

Robert J. Amdur, MD Ernest L. Mazzaferri, MD, MACP Department of Radiation Oncology Department of Medicine

University of Florida College of Medicine University of Florida College of Medicine 2000 S.W. Archer Road 2000 S.W. Archer Road

Gainesville, FL 32610-0385 Gainesville, FL 32610-0385

USA USA

ESSENTIALS OF THYROID CANCER MANAGEMENT

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ISBN-10: 0-387-25713-6 e-ISBN: 0-387-25714-4 Printed on acid-free paper.

ISBN-13: 978-0387-25713-6

C 2005 Springer Science+Business Media, Inc.

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CONTENTS

Contributing Authors xiii Acknowledgement xv Preface xvii

PART 1. INTRODUCTION 1 1.1. Basic Thyroid Anatomy 3

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 1.2. Thyroid and Parathyroid Physiology 7

ERNEST L.^MAZZAFERRI,^MD,MACP AND ROBERT J.^AMDUR,^MD

1.3. Pathology and Classification of Thyroid Carcinoma 19

HEATHER M.^BROWN,^MD,^{ROBERT J}.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,

MD,^MACP

1.4. The American Joint Committee on Cancer System of Staging Thyroid Cancer 33

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 2. DIAGNOSIS AND IMAGING OF THYROID CANCER 37 2.1. The Diagnosis of Thyroid Cancer 39

ERNEST L.^MAZZAFERRI,^MD,^MACP

vi Contents

2.2. Definitions: Thyroid Uptake Measurement, Thyroid Scan, and Whole Body Scan 49

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 2.3. Thyroid Stunning 55

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 2.4. The Role of a Diagnostic Radioiodine Whole Body Scan

(DxWBS) 61

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

2.5. The Value of a Post-Treatment Whole Body Scan 65

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

2.6. Examples of Radioiodine Whole Body Scans 69

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 2.7. Computerized Tomography (CT) and Magnetic Resonance (MR)

Imaging of Thyroid Cancer 91

ILLONA M.SCHMALLFUSS,^MD,^{ROBERT J}.^AMDUR,^MD,^{DOUGLAS B}.^VILLARET,

MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

2.8. Positron Emission Tomography (PET) of Thyroid Cancer 95

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

2.9. Neck Ultrasonography in Patients with Thyroid Cancer 101

ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 3. INCIDENCE AND PROGNOSIS OF DIFFERENTIATED THYROID CANCER 121

3.1. Incidence, Prevalence, Recurrence, and Mortality of Differentiated Thyroid Cancer 123

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

3.2. Factors That Predict Cancer Recurrence and Death from Differentiated Thyroid Cancer 131

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 4. SURGICAL THERAPY OF DIFFERENTIATED THYROID CANCER 141

4.1. A Total Thyroidectomy Rarely Removes All Thyroid Tissue 143

DOUGLAS B.^VILLARET,^MD,^{ROBERT J}.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,

MD,^MACP

Contents vii

4.2. Neck Dissections to Remove Malignant Lymph Nodes 147

DOUGLAS B.^VILLARET,^MD,^{ROBERT J}.^AMDUR,^{MD AND}

ERNEST L.^MAZZAFERRI,^MD,^MACP

4.3. Potential Complications of Thyroid Cancer Surgery 153

DOUGLAS B.^VILLARET,^MD,^{ROBERT J}.^AMDUR,^{MD AND}

ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 5. MEDICAL THERAPY OF DIFFERENTIATED THYROID CANCER 161

A. BACKGROUND INFORMATION AND PROCESS ADMINISTRATION 163

5A.1. Half-life and Emission Products of I-131 165

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 5A.2. Choosing the Activity of I-131 for Therapy 169

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

5A.3. Requirements for Outpatient Release Following I-131 Therapy 177

ROBERT J. ^AMDUR, ^MD, GEORGE SNYDER,AND ERNEST L. ^MAZZAFERRI,

MD,^MACP

5A.4. A Checklist of Things to do at the Clinic Visit Prior to I-131 Therapy 183

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5A.5. A Checklist of Things to do on the Day of I-131

Administration 189

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5A.6. Documents That Facilitate I-131 Scheduling and

Patient Education 193

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

B. PREPARING PATIENTS FOR I-131 THERAPY 203 5B.1. The Low-Iodine Diet 205

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

5B.2. Intravenous Iodinated Contrast Effects Iodine Uptake for Months 211

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5B.3. Measuring Urinary Iodine (UI) 215

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

viii Contents

5B.4. Using Lithium Carbonate to Increase the Effectiveness of I-131 221

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5B.5. Thyroid Hormone Withdrawal to Elevate TSH 229

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5B.6. Recombinant Human TSH: Background Information and Standard

Protocol 233

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

5B.7. Using rhTSH prior to I-131 Therapy 239

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

C. THYROID REMNANT ABLATION 247

5C.1. I-131 Therapy in a Patient with a Small Thyroid Remnant 249

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

5C.2. I-131 Therapy in a Patient with a Large Thyroid Remnant 257

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP

D. SUPPRESSION OF TSH AND THE POTENTIAL TOXICITY OF I-131 THERAPY 261

5D.1. Effects of Suppressing TSH on Tumor Growth and Recurrence 263

ERNEST L. ^MAZZAFERRI,^MD,^MACP

5D.2. Potential Side Effects and Complications of I-131 Therapy 267

ROBERT J.^AMDUR,MD AND ERNEST L. ^MAZZAFERRI,^MD,^MACP 5D.3. Management of Xerostomia, Taste Impairment and

Dental Prophlaxis 281

ROBERT J.^AMDUR,^MD,^{PAMELA L}.^SANDOW,^DMD,^{WILLIAM M}.^MENDENHALL,

MD,AND ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 6. FOLLOW-UP PROTOCOL AND TREATMENT OF RECURRENT OR METASTATIC DIFFERENTIATED THYROID CANCER 285

6.1. An Overview of Follow-up of Differentiated Thyroid Cancer 287

ERNEST L.^MAZZAFERRI,^MD,^MACP

6.2. Follow-up of Differentiated Thyroid Cancer Using Serum Thyroglobulin Measurements 295

ERNEST L.^MAZZAFERRI,^MD,^MACP

Contents ix

6.3. Overview of Management of Differentiated Thyroid Carcinoma in Patients with Negative Whole Body Radioiodine Scans and Elevated Serum Thyroglobulin Levels 303

ERNEST L.^MAZZAFERRI,^MD,^MACP

6.4. Treatment Guidelines When the Only Evidence of Disease is an Elevated Serum Thyroglobulin Level 313

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

6.5. Treatment of Residual Differentiated Thyroid Cancer in the Neck and Mediastinum 317

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 6.6. Treatment of Lung Metastases from Differentiated

Thyroid Cancer 319

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 6.7. Treatment of Bone Metastases from Differentiated

Thyroid Cancer 329

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 6.8. Treatment of Spinal Cord Compression from Metastatic

Thyroid Cancer 337

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

6.9. Treatment of Brain Metastasis from Differentiated Thyroid Cancer 341

ROBERT J.^AMDUR,^MD,^{ILLONA M}.^SCHMALFUSS,AND ERNEST L.

MAZZAFERRI,^MD, ^MACP

PART 7. DIFFERENTIATED THYROID CANCER DURING PREGNANCY, IN A THYROGLOSSAL DUCT, AND UNFAVORABLE HISTOLOGIC SUBTYPES OF DTC 345 7.1. Management of Differentiated Thyroid Cancer During Pregnancy 347

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

7.2. Thyroid Cancer Originating in a Thyroglossal Duct Remnant 351

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 7.3. Tall and Collumnar Variants of Papillary Carcinoma 355

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 7.4. Diffuse Sclerosing Variant of Papillary Carcinoma 359

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 7.5. H ¨urthle Cell Carcinoma 361

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

x Contents

7.6. Insular and Other Poorly Differentiated Thyroid Carcinomas 365

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 7.7. Anaplastic Carcinoma 369

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

PART 8. MEDULLARY THYROID CANCER 375

8.1. Diagnosis and Management of Medullary Thyroid Carcinoma 377

ERNEST L.^MAZZAFERRI,^MD,MACP AND NICOLE A.^MASSOLL,^MD

PART 9. EXTERNAL BEAM RADIATION THERAPY 403 9.1. External Beam Radiotherapy Dose Schedules 405

ROBERT J.^AMDUR,^MD,^{SIYONG KIM},^Ph^D,JONATHAN GANG LI,^Ph^D,^CHIRAY

LIU,^Ph^D,^{WILLIAM M}.^MENDENHALL,^MD,AND ERNEST L.^MAZZAFERRI,^MD,

MACP

9.2. Indications for External Beam Radiation Therapy for Differentiated Thyroid Cancer 407

ROBERT J.^AMDUR,^MD,^{WILLIAM M}.^MENDENHALL,^MD,^AND

ERNEST L. ^MAZZAFERRI, ^MD, ^MACP

9.3. Sequencing of I-131 and External Beam Radiation Therapy for Differentiated Thyroid Cancer 413

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP 9.4. Indications for EBRT for Medullary and Anaplastic

Thyroid Carcinoma 415

ROBERT J.^AMDUR,^MD,^{WILLIAM M}.^MENDENHALL,^MD,^AND

ERNEST L. ^MAZZAFERRI, ^MD, ^MACP

9.5. Conventional Radiotherapy Technique for Treating Thyroid Cancer 419

ROBERT J.^AMDUR,^MD,^{SIYONG KIM},^Ph^D,JONATHAN GANG LI,^Ph^D,^CHIRAY

LIU,^Ph^D,^{WILLIAM M}.^MENDENHALL,^MD,AND ERNEST L.^MAZZAFERRI,^MD,

MACP

9.6. Intensity Modulated Radiation Therapy for Thyroid Cancer 425

ROBERT J.^AMDUR,^MD,^{SIYONG KIM},^Ph^D,JONATHAN GANG LI,^Ph^D,^CHIRAY

LIU,^Ph^D,^{WILLIAM M}.^MENDENHALL,^MD,AND ERNEST L.^MAZZAFERRI,^MD,

MACP

Contents xi

9.7. Drawing Target Volumes for Intensity Modulated Radiation Therapy for Thyroid Cancer 433

ROBERT J.^AMDUR,^MD,JONATHAN GANG LI,^Ph^D,^{SIYONG KIM},^Ph^D,^CHIRAY

LIU,^Ph^D,^{WILLIAM M}.^MENDENHALL,^MD,AND ERNEST L.^MAZZAFERRI,^MD,

MACP

9.8. Potential Toxicity of External Beam Radiotherapy for Thyroid Cancer 439

ROBERT J.^AMDUR,^MD,^{WILLIAM M}.^MENDENHALL,^MD,^AND

ERNEST L. ^MAZZAFERRI, ^MD,^MACP

PART 10. REFERENCE INFORMATION FOR PHYSICIANS AND PATIENTS 443 10.1. Resource Websites 445

ROBERT J.^AMDUR,MD AND ERNEST L.^MAZZAFERRI,^MD,^MACP

Index 447

CONTRIBUTING AUTHORS

Robert J. Amdur, MD Professor

Department of Radiation Oncology University of Florida

College of Medicine Heather M. Brown, MD Assistant Professor

Department of Pathology,

Immunology and Laboratory Medicine University of Florida

College of Medicine Jonathan Gang Li, PhD Assistant Professor

Department of Radiation Oncology University of Florida

College of Medicine

Siyong Kim, PhD Assistant Professor

Department of Radiation Oncology University of Florida

College of Medicine Chiray Liu, PhD Associate Professor

Department of Radiation Oncology University of Florida

College of Medicine Nicole A. Massoll, MD Assistant Professor

Department of Pathology, Immunology and Laboratory Medicine

University of Florida College of Medicine

xiv Contributing Authors

Ernest L. Mazzaferri, MD, MACP Professor

Department of Medicine University of Florida College of Medicine, and Emeritus Professor and Chairman of Internal Medicine Ohio State University

William M. Mendenhall, MD Professor

Department of Radiation Oncology University of Florida

College of Medicine Pamela L. Sandow, DMD Clinical Associate Professor

Department of Oral and Maxillofacial Surgery and Diagnostic Sciences University of Florida

College of Dentistry

Illona M. Schmallfuss, MD Assistant Professor

Department of Radiology University of Florida College of Medicine George Snyder Radiation Safety Officer

Shands Hospital, Gainesville, Florida Douglas B. Villaret, MD

Assistant Professor

Department of Otolaryngology University of Florida

College of Medicine

ACKNOWLEDGEMENT

We thank Chris Morris for helping us get permission to use figures from other publi- cations and Jessica Kirwan for preparing the manuscript.

PREFACE

The goal of this book is to provide Endocrinologists, Surgeons, Nuclear Medicine Physicians, and Radiation Oncologists with practical advice about managing patients with thyroid cancer. This book will not replace the excellent publications that focus on a highly specific topic or provide an exhaustive review of major sub- jects from the perspective of a particular specialty. These kinds of publications will always be an important source of information for both students and experi- enced practitioners. The void that we see is the lack of a single, concise, up-to- date reference that is applicable to all of the specialists who make clinical deci- sions about thyroid cancer patients. Essentials of Thyroid Cancer Management will fill this void in a manner that is both user-friendly and technically comprehen- sive.

For reading efficiency, this book contains the minimum of text required to explain how to make sound clinical decisions in specific situations. We rely heavily on tables, diagrams, graphs, photographs, and other figures to convey this information. Subjects are addressed in a large number of chapters that each focus on a relatively narrow topic.

In some cases, there is overlap between the information in multiple different chapters so the reader does not have to page back and forth between different sections of the book.

As occurs in every area of medicine, there is controversy about important issues in the management of thyroid cancer. We think explanations are most effective when they are concise and definitive. For this reason, we present our opinions and recommendations

xviii Preface

and simply note when others have divergent views. In most chapters, this book describes only one way of managing thyroid cancer patients. Reasonable people will disagree with some of the recommendations in this book and we respect the alternative viewpoints of our colleagues.

Robert J. Amdur and Ernest L. Mazzaferri