Standard of Care Treatment for Patients With Advanced RAI-Refractory DTC

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An overview of the standard of care treatment for patients with advanced radioiodine-refractory differentiated thyroid cancer.

Case: A 64-Year-Old Woman with DTC

Initial presentation

  • A 64-year-old woman presents with a painless “lump on her neck” with occasional swelling. She states she noticed this just a few days after returning from vacation.
  • PMH: Hyperlipidemia managed with medication; COPD
  • PE: palpable, non-tender solitary right-of-the midline neck mass; mobile supraclavicular mass on the same side; otherwise unremarkable


Clinical workup and initial treatment

  • Labs: TSH WNL
  • Ultrasound of the neck revealed a 3.3-cm suspicious right mass in the lobe of the thyroid; 2 suspicious supraclavicular lymph nodes (LNs), largest 2.0 cm in size.
  • Ultrasound-guided FNAB of the thyroid mass and the largest LN confirmed papillary thyroid carcinoma.
  • Patient underwent total thyroidectomy with central compartment node dissection and right selective neck dissection.
    • Pathology: 3.0-cm papillary thyroid cancer, columnar cell variant; 4/14 lateral positive LN, 3/3 central positive LN​
    • Largest lateral node was 2.2 cm with no extra-nodal extension
    • Margins were negative
    • Microscopic extrathyroidal extension present
  • Probable stage II; T2N1bM0 papillary thyroid cancer


Subsequent treatment and follow-up

  • She was treated with radioactive iodine 150 millicuries
    • Whole body scan showed uptake in the neck, consistent with remnant thyroid tissue
  • She was started on levothyroxine suppression therapy
  • Follow-up at 6 months
    • TSH 0.1 µU/mL, thyroglobulin 24 ng/mL (negative anti-thyroglobulin antibodies)
    • Chest CT scan showed 8 small bilateral lung nodules only several mm in size
  • Next-generation sequencing was negative for mutations, rearrangements
  • Follow-up CT chest scan and blood tests 3 months later
    • Thyroglobulin increased
    • Lung nodules had increased by up to 1 cm in size
  • Lenvatinib 24mg po qd was initiated
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