Lenvatinib Treatment Considerations in RAI-R-DTC

EP: 1.Patient Profile: A 43-Year-Old Man with RAI-R-DTC

EP: 2.Overview of Radioiodine-Refractory Differentiated Thyroid Cancer (RAI-R-DTC)

EP: 3.Treatment Landscape for Patients with Advanced RAI-R-DTC

EP: 4.Standard-of-Care Treatment for Patients with Advanced RAI-R-DTC

EP: 5.Treatment Selection for Patients With RAI-R-DTC

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EP: 6.Lenvatinib Treatment Considerations in RAI-R-DTC

EP: 7.Data on Age and Randomization of Dose in Patients with RAI-R-DTC

EP: 8.Treatment Sequencing and Advice for Community Oncologists Treating RAI-R-DTC

Case: A 43-Year-Old Man with RAI-R-DTC

Initial presentation and initial treatment:

• A 43-year-old man presents with fatigue, neck pain and dysphagia and was diagnosed with papillary thyroid carcinoma 10 years ago
• Following a total thyroidectomy, he underwent multiple rounds of radioactive ablation therapy.
• Initial response was positive with undetectable thyroid globulin levels and negative imaging
• PMH: Hyperlipidemia; Hypertension; Diabetes (controlled with medications)
• SH: lives with his wife and 2 teenage children; non-smoker and drinks alcohol occasionally
• PE: appears fatigued with a palpable thyroid nodule in the left lobe
• Neck examination: palpable mass in the left neck, and cervical lymphadenopathy

Clinical workup

• Labs: WNL
• Neck ultrasound: Identifies a large, irregular mass in the left thyroid bed with invasion into surrounding structures.
• CT of the neck and chest revealed neck mass along with multiple pulmonary nodules, largest 2cm x 1.5cm
• TSH: Within normal limits
• Thyroglobulin levels: Markedly elevated
• Radioactive iodine scan: Confirms radioiodine refractory disease with widespread involvement of cervical lymph nodes and distant metastases.
• Needle biopsy was performed which confirmed Papillary thyroid cancer. Next-generation sequencing was negative for mutations, rearrangements

Subsequent treatment and follow-up

• Lenvatinib 24mg po qd was initiated

This is a video synopsis/summary of a Case-Based Peer Perspectives featuring Marcia S. Brose, MD, PhD.

Brose shares her extensive experience in treating patients with lenvatinib since 2007. Despite the potential for lower blood pressure issues when starting at a lower dose, data has shown that starting at a lower dose leads to less efficacy but the same amount of grade 3 adverse events and patient concerns. Therefore, nearly all of her patients start at the 24 mg dose, with close monitoring at 1, 2, and 4 weeks. The only exceptions are patients with frank tracheal invasion, where starting at a lower dose or using sorafenib may be considered to avoid creating a life-threatening fistula, or extremely frail patients with multiple medical issues.

Brose emphasizes that the tolerability profile does not significantly change with lower doses, so it is best to manage adverse reactions while maintaining the more efficacious higher dose. Heart failure is another consideration, as lenvatinib may have a greater cardiovascular effect than sorafenib. However, even patients with heart failure can be successfully rechallenged with lenvatinib at lower doses after a break from the drug. Comorbidities should not prevent treatment but rather warrant closer attention during treatment.

Video synopsis is AI-generated and reviewed by Targeted Oncology™ editorial staff.