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External beam radiotherapy for differentiated thyroid cancer locoregional control
- 1. AHNS Endocrine Surgery Section Guidelines https://endocrine.ahns.info External-beam Radiotherapy for Differentiated Thyroid Cancer Locoregional Control: A Statement of the American Head and Neck Society AP Kiess, N Agrawal, JD Brierley, U Duvvuri, RL Ferris, E Genden, RJ Wong, RM Tuttle, NY Lee, GW Randolph
- 2. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Kiess AP, et al. (2016), Externalâbeam radiotherapy for differentiated thyroid cancer locoregional control: A statement of the American Head and Neck Society. Head Neck, 38: 493-498.
- 3. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠External beam radiotherapy (EBRT) for differentiated thyroid cancer (DTC) is debated due to lack of prospective studies ⢠Surgery and radioactive iodine usually effective for locoregional control ⢠Recent retrospective studies report benefit in select patients ⢠Goal of EBRT is to improve locoregional control while limiting treatment toxicity Background
- 4. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Risk factors for locoregional recurrence: ⢠Incomplete tumor resection ⢠Macroscopic extrathyroidal extension (T4a) ⢠Invasion of aerodigestive tract (trachea, larynx, esophagus) ⢠Large volume lymph node involvement (>3cm) ⢠Extranodal extension ⢠Unfavorable histology Background
- 5. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Multidisciplinary writing group convened by the AHNS Endocrine Surgery Section ⢠Literature search of EBRT directed to papillary, follicular or Hurthle cell carcinomas ⢠Recommendations based on existing guidelines and literature ⢠Endorsed by AHNS QOC and council Methods
- 6. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠EBRT is recommended for patients with gross residual or unresectable locoregional disease, except for patients <45 years old with limited gross disease that is RAI-avid Recommendation 1
- 7. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Multiple retrospective studies show improved long-term locoregional control with EBRT ⢠Chow et al found in 217 patients with PTC with gross residual disease a 10-yr LRR-free survival of 63% with EBRT compared to 24% without EBRT ⢠In 66 patients with gross DTC treated with EBRT, Romesser et al reported a 3 year local PFS of 73% without concurrent chemotherapy versus 90% with concurrent chemotherapy Gross Residual or Unresectable Disease Chow SM, et al. Local and regional control in patients with papillary thyroid carcinoma: specific indications of external radiotherapy and radioactive iodine according to T and N categories in AJCC 6th edition. Endocr Relat Cancer 2006;13:1159â1172. Romesser PB, et al. External beam radiotherapy with or without concurrent chemotherapy in advanced or recurrent non- anaplastic non-medullary thyroid cancer. J Surg Oncol 2014;110:375â382.
- 8. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Patients under 45 years old have lower risk for locoregional progression ⢠RAI alone may achieve excellent locoregional control ⢠Higher risk of radiation-related 2nd malignancy in young patients Young Patients with Limited RAI-Avid Disease
- 9. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠EBRT should not be routinely used as adjuvant therapy after complete resection of gross disease Recommendation 2
- 10. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Adjuvant EBRT highly debated ⢠No routine EBRT indications ⢠Surgery and radioactive iodine usually effective for locoregional control ⢠Multidisciplinary discussion critical EBRT after Complete Resection
- 11. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠After complete resection, EBRT may be considered in select older patients with high likelihood of microscopic residual disease and low likelihood of responding to RAI Recommendation 3
- 12. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠High likelihood of microscopic residual disease if: ⢠Tumor is shaved off RLN to spare function ⢠Tracheal or laryngeal shave excision is performed for cartilage invasion ⢠Resection of involved esophageal muscularis is required ⢠Extensive extracapsular nodal spread requiring jugular vein sacrifice ⢠Positive margins Microscopic Residual Disease
- 13. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Low likelihood of responding to RAI if: ⢠Unfavorable histology ⢠Recurrent disease after prior RAI ⢠Low RAI uptake on whole body scan when known residual disease present ⢠High FDG uptake on PET Response to RAI
- 14. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Keum et al examined 68 patients with PTC invading trachea managed with tracheal shave ⢠Majority of patients with positive margins ⢠EBRT significantly decreased LRR from 51% to 8% EBRT after Tracheal Shave Excision Keum KC, et al. The role of postoperative external- beam radiotherapy in the management of patients with papillary thyroid cancer invading the trachea. Int J Radiat Oncol Biol Phys 2006;65:474â 480.
- 15. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Chow et al showed that 131 patients with resected pT4a PTC had better 10-yr LRFS after EBRT plus RAI (88%) compared to RAI alone (72%) or EBRT alone (60%) ⢠Those with pT4a seemed to derive more benefit from EBRT than those with stage pT3b. ⢠Patients with positive margins also had improved LRFS after EBRT plus RAI (90%) compared to RAI alone (80%) or EBRT alone (57%). EBRT for Positive Margins Chow SM, et al. Local and regional control in patients with papillary thyroid carcinoma: specific indications of external radiotherapy and radioactive iodine according to T and N categories in AJCC 6th edition. Endocr Relat Cancer 2006;13:1159â1172.
- 16. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Cervical lymph node involvement alone should not be an indication for adjuvant EBRT Recommendation 4
- 17. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Adjuvant RAI is usually effective for microscopic nodal disease ⢠Nodal recurrences often treated with neck dissection, but serial re-operation also has morbidity ⢠Consider EBRT in cases of large volume nodal disease, significant extranodal extension, or multiple recurrences Cervical Nodal Involvement
- 18. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠For patients with distant metastases, importance of locoregional control should be weighed against overall prognosis and potential toxicities of EBRT Recommendation 5
- 19. AHNS Endocrine Surgery Section - https://endocrine.ahns.info ⢠Avoid normal structures using IMRT ⢠Limit dose per daily fraction to 2.0Gy (late toxicity related to dose per fraction) ⢠Decrease volume of radiation especially when no or limited nodal involvement ⢠Multidisciplinary support: ⢠Speech/swallow therapy ⢠Nutrition ⢠Dental Strategies to Reduce EBRT Toxicities
- 20. AHNS Endocrine Surgery Section - https://endocrine.ahns.info Strategies to Reduce EBRT Toxicities
- 21. AHNS Endocrine Surgery Section - https://endocrine.ahns.info External-beam Radiotherapy for Differentiated Thyroid Cancer Locoregional Control: A Statement of the American Head and Neck Society AP Kiess, N Agrawal, JD Brierley, U Duvvuri, RL Ferris, E Genden, RJ Wong, RM Tuttle, NY Lee, GW Randolph
Hinweis der Redaktion
- In a large Hong Kong study, patients with papillary thyroid cancer with gross residual disease (n = 217) had 10-yr LRR-free survival of 63% with EBRT compared to 24% without EBRT (P < 0.001).(3) At Memorial Sloan-Kettering Cancer Center (MSKCC), 66 patients with gross non-anaplastic non-medullary thyroid cancer were treated with EBRT, resulting in 3-yr local progression-free survival of 73% without concurrent chemotherapy and 90% with concurrent chemotherapy (although the effect of adding chemotherapy was greatest in patients with poorly differentiated histology
- In young patients (< 45 yr old) with limited gross residual disease that is RAI-avid, EBRT is usually not recommended. These patients have lower risk for locoregional progression and, in the setting of small-volume disease, RAI alone may achieve excellent control. Even when post-RAI whole body scans showed residual small-volume disease in the neck, TSH-stimulated RAI resulted in 70% LRC with a median of 2.7 yr follow-up. (A) rhTSH stimulated diagnostic 123I scan prior to RRA (top panel) and the postablation scan obtained on day 6 after ablation (bottom panel) in a patient with an incidentally discovered area of RAI uptake just inferior to the sternal notch marker (arrow). Medan administered activity rhTSH-RRA 144mCi. (B) Diagnostic scan obtained at 13 months after ablation showing resolution of the RAI-avid lesion and an undetectable stimulated Tg at follow-up. Tg, thyroglobulin.
- In a Korean study of 68 patients who underwent shave excision of thyroid tumor off the trachea, EBRT significantly decreased LRR from 51% to 8% (P < 0.01)