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I am Endocrinologist from Buenos Aires, Argentina and I have a troublesome case.The patient is a 59 years old male. His thyroid cancer was diagnosed because of bone metastasis 9 years ago. At that time(1996) he underwent thyroidectomy (moderately differenTiated follicular thyroid carcinoma) and received 200 mC I 131.
After 6 months the serum TG level (under supPressive T4 treatment) was 1250 ng/ml.
He had extensive bone metastasis in the spine, with a predominatE paravertebral mass at T4 level, with extension to the vertebral body, pedicle, posterior archEs, and erosion of them. The lesion extended to the spinal canal and the spinal cord was displaced anteriorly. The patient had pain but not compressive spinal cord symptoms. There were lesions in other vertebral bodies suggestive of metastasis. L1 presented partial wedging.
Surgery to debulk the dominant paravertebral mass at T4 level was postulated but refused.Then he begun to receive 200 mC I 131 every six months up to a total dose of 1400 mC, with reduction of the dominant mass
His tiroglobulin decreased gradually to 14 ng/ml (under supression) and was mantained at the same level 3 years after the last dose, which was given nov 2000. The MRI images remained unchanged.
The TG began to increase in the last two years and dramatically in the last year ( TG: 2020 ng /ml in 07/06 and in 03/07 more than 3000 ng/ml)
The MRI reveals a mass growing from the L4 (which is now crushed) and infiltrating the psoas.
The patient feels very well, has no pain and is doing his habitual work, but I know that this situation perhaps will not last much more time. The possibility of having dosimetry in our country is very poor.
The white blood cell and platelet count are normal but in the inferior limits. The Anti TG antibodies always negative.
I really will appreciate your opinion and advice.
Mar'a J. Pozzo MD
Hospital Alem'n
Buenos Aires, Argentina
Response
This is a very difficult situation for this 59 year-old man with stage IVC follicular thyroid carcinoma. Radioiodine seems to have had some benefit, but he has extensive bone metastases that appear to be progressive. This is also a poor progonstic factor for survival. One option is to provide palliative therapy to symptomatic bone lesions, primarily through limited external beam radiotherapy and use narcotics to provide pain relief.
A more aggressive approach (since the patient appears to have a good functional status) would be to use external beam radiotherapy or chemoembolization for the largest, most progressive lesions and intravenous bisphosphonates (pamidronate or zolendronic acid) to protect bone strength, reduce fracture risk and relieve some pain.
In the United States, we would consider such a patient (good functional status and progressive metastases) for clinical trials with agents that inhibit angiogenesis, other tyrosine kinases, proteasomes or phase I clinical trials of even more novel agents/combinations. Entry of these patients into clinical trials, if available is an excellent option.
For consideration of systemic therapy outside of clinical trials, we have used combination chemotherapy (adriamycin and paclitaxel) with some anecdotal success. Clinical trials of single agent chemotherapy are disappointing. We have also considered more novel agents (sunitinib, gefitinib or other agents approved for other cancers) but there is limited data supporting such use. Finally, there has been some limited success using thalidomide in patients with end-stage disease for disease stabilization and help with pain, anxiety and difficulty sleeping.
Bryan Haugen, MD