Endocrine Abstracts

Current indications for adjuvant Radioactive Iodine (RAI) in low- and intermediate-risk differentiated thyroid cancer (DTC) are controversial. At the same time, there is universal consensus for personalized DTC management according to individual patient needs, as there does not appear to be a ‘‘right’’ way to treat patients with DTC. According to the Martinique Principles ¹, adjuvant RAI treatment has many goals, including: initial staging of the disease, facilitate follow-up, improve disease-specific survival, decrease recurrence, improve progression-free survival and, in some cases, curative intent. The same principles state that the key elements in adjuvant treatment decision-making are post-op risk assessment, impact on outcomes of interest, side effect profile, patient values and preferences, improved initial staging, and facilitate sensitive follow-up. In addition, other factors must be consider such as the availability and quality of pre- and post-op ultrasound, the quality of RAI imaging, thyroglobulin assay accuracy, the access to an experienced thyroid surgeon, the presence of anti-thyroglobulin antibodies and preferences of local disease management multidisciplinary team. All these factors (or a combination of them) could tip the balance for or against adjuvant RAI administration in DTC. There are fresh retrospective data showing that a decrease in the administration of adjuvant RAI in low- to intermediate-risk DTC individuals generates a substantial number of patients stranded in a misleading status labeled as “gray zone”². These patients are those appropriately identified as indeterminate or biochemical incomplete response to treatment when ablative RAI is administered. A large number of patients in a broad “gray zone” could likely complicate their follow-up, with more diagnostic tests that will lead to increasing costs and raise the anxiety level of both patient and attending physician. A very recent European Thyroid Association Consensus Statement³, recommends adjuvant RAI in intermediate-risk DTC patients who meet any of the following frequent conditions: advanced age (>45), aggressive histology, increase volume of nodal disease, extranodal extension, multiple lymph node or lymph node outside the central neck. In this conundrum we should bear in mind that changes that downgrade the intensity in the treatment of oncologic patients are normally based on the results emerging from large tertiary academic hospitals (those which are most often published). However, these results may not accurately reflect real-life outcomes. In other words, broad recommendations are not always applicable to individual cases. Finally, any proposal for change in the practice of medicine must be considered in light of both its ethical aspects and the precautionary principle, the latter emphasizes caution, pausing and review before embracing innovations that may in time prove disastrous.

References

1. Tuttle RM, et al. Thyroid. 2019; 29: 461-470.

2. Grani G, et al. J Clin Endocrinol Metab. 2021; 106: e1717-e1727.

3. Pacini F, et al. Eur Thyroid J .2022; 11: e210046.