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

EP: 1.Patient Profile: A 64-Year-Old Woman With DTC

EP: 2.Clinical Insights on a 64-Year-Old Woman With DTC

EP: 3.Current Treatment Landscape for Patients With Advanced RAI-Refractory DTC

EP: 4.DTC Treatment: Safety Profiles for Sorafenib and Lenvatinib

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EP: 5.Standard of Care Treatment for Patients With Advanced RAI-Refractory DTC

EP: 6.Real-World Data on Older Patients With RAI-Refractory DTC

EP: 7.Molecular Testing in Patients With Advanced RAI-Refractory DTC

EP: 8.Treating Patients With BRAF V600E Mutation and Advanced RAI-Refractory DTC

EP: 9.Second-Line Treatment and Future of Treating Advanced RAI-Refractory DTC

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

This is a video synopsis/summary of a Case-Based Peer Perspective featuring Lori Wirth, MD.

Wirth discusses the National Comprehensive Cancer Network guidelines for patients with progressive radioactive iodine (RAI)–refractory differentiated thyroid cancer (DTC). The guidelines recommend molecular diagnostics whenever possible before initiating therapy due to the availability of gene-specific first-line treatment options, such as larotrectinib or entrectinib for NTRK fusion–positive patients and selpercatinib or pralsetinib for RET fusion–positive disease. Lenvatinib has a preferred category 1 recommendation for progressive RAI-refractory DTC without oncogenic gene fusions, while sorafenib also has a category 1 recommendation.

One challenge in initiating treatment is determining the appropriate timing. Asymptomatic patients with a low disease burden and slow growth may not require immediate therapy, and ongoing disease monitoring and thyroid-stimulating hormone suppression may be the most appropriate approach. However, patients with rapidly progressive RAI-refractory DTC or those likely to develop disease progression symptoms should initiate treatment. Subset analyses from the SELECT trial suggest that symptomatic patients do not respond to treatment, emphasizing the importance of not waiting until symptoms develop before starting therapy.

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