Japanese Journal of Clinical Oncology 32:202-205 (2002)
© 2002 Foundation for Promotion of Cancer Research
Disposition of Radioiodine 131I Therapy for Thyroid Carcinoma in a Patient with Severely Impaired Renal Function on Chronic Dialysis: a Case Report
Departments of 1 Medical Oncology and 2 Nuclear Medicine, Centre Antoine Lacassagne, Nice and 3 Department of Nephrology, Hôpital Pasteur, Nice, France
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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The aim of this study was to analyze the disposition of radioiodine used for the ablation of thyroid remnants after radical surgery for a differentiated thyroid carcinoma in a patient on chronic hemodialysis in order to deliver the optimal 131I dose to improve the healing rate in these rare cases and to serve as a useful reference to other health care professionals who might face a similar dilemma. A 50 mCi dose of 131I was administered orally and dialysis sessions were performed 24, 72 and 144 h after therapy. Patient effluent dialyzate waste samples were collected and blood radioactivity analyses were performed at each dialysis session. The 131I disposition half-life was 2.7 ± 0.8 h. The amounts of remnant radioactivity in total body patient were 58.7, 38.9 and 27.1%, respectively, after each of the three dialysis sessions and the effective period calculated was 1.4 days. The extents of water purification in blood were 69.7, 47.9 and 22.7% at the beginning of each dialysis and 37.7, 42.8 and 18.1% at the end of each dialysis. Effective periods of radioiodine for thyroid cancer in a patient on hemodialysis resulted in rapid iodine clearance, thereby reducing the effective radiation dose and promoting the need to use larger treatment doses. Hemodialysis was safe and effective during treatment with radioiodine.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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Well-differentiated thyroid carcinomas are potentially curable tumors, with a generally good prognosis and a mortality varying from 11 to 17%. Several factors influence the prognosis, and invasion of adjacent structures by thyroid tumors has important negative implications. Most authors agree that the best treatment for differentiated thyroid cancer is aggressive surgical treatment with negative microscopic margins for locoregional control of the disease (1). The postoperative treatment of patients, particularly relating to radioiodine therapy, is controversial. The lack of well-designed, randomized controlled studies and the low probability that any large multicenter treatment studies will ever come to fruition force the clinician to rely on retrospective studies and surveys of practice experience. Radioiodine therapy of differentiated thyroid cancer is based on the ability of these tumors to accumulate iodine, making them accessible to a metabolic treatment with 131I, a ß-emitting radioisotope leading to intensive, highly selective and tumoricidal irradiation of such cells. Radioiodine ablation of thyroid remnants is performed a few weeks after radical thyroid surgery and significantly decreases, on the one hand, the risk of recurrence of thyroid cancer and, on the other, the risk of death due to thyroid cancer. Even in recurrent or metastatic thyroid cancer, radioiodine treatment will often be curative or at least result in long-term improvement, making differentiated thyroid cancers among the most curable cancers at present.
The dose of radioactive iodine required to ablate thyroid remnants following surgery for differentiated thyroid carcinoma is not standardized. Typical administered activities range from <30 up to 150 mCi, reflecting local practice and regulations governing allowable outpatient doses, but the appropriate dose of 131I remains undetermined even in patients with poor renal function (2). The purpose of this study was to analyze the disposition of radioiodine used after radical surgery for a differentiated thyroid carcinoma in a 43-year-old male with severely impaired renal function on chronic hemodialysis in order to deliver the optimal 131I dose to improve the healing rate in these rare cases and to serve as a useful reference to other health care professionals who might face a similar dilemma.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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A 43-year-old man had an end-stage renal disease due to chronic glomerulonephritis that appeared at the age of 31 years and was on chronic hemodialysis. Unfortunately, a 2 cm diameter right thyroid lobe mass was discovered by clinical examination. After a fine-needle biopsy, which revealed papillary thyroid carcinoma, and to evaluate the extent of disease, whole-body 131I scans were performed. The diagnosis obtained was a locally well-differentiated thyroid cancer without metastasis. The surgical procedure was total thyroidectomy with right modified neck dissection for a multinodular goiter. Pathological examination showed multi-focal papillary carcinoma in both lobes with extension into surrounding soft tissues. There were metastases in nine of 16 cervical nodes. After extensive discussions (over a 6 month period) with the patient, his family, dialysis personnel and health physics personnel concerning radioiodine metabolism, clearance and radiation safety, radioiodine therapy was programmed. The patient was admitted for treatment to a hospital room that was prepared according to the institution’s procedures for radiation contamination control during radioiodine therapy and was administered 50 mCi of 131I orally (based on literature analysis, we administered 50% of the currently precribed activity for ‘high-risk patients’; see Discussion section). Dialysis sessions were performed 24, 72 and 144 h after therapy. Patient effluent dialyzate waste samples were collected every 4 min during 3.5 h and blood radioactivity samples were drawn (from the arteriovenous fistula) every 30 min during 3.5 h in each dialysis session. Radioactivity measurements were performed with a calibrated gamma counter.
The 131I half-life (t) calculated on dialyzate waste samples was 2.7 ± 0.8 h (mean for three dialysis sessions ± standard deviation). Figs 1, 2 and 3 show the 131I urinary concentration profile for each dialysis and mimic nephrograms comparable to those observed in patients with normal functional kidneys. The amounts of remnant radioactivity in the total body were 58.7, 38.9 and 27.1% after each of the three dialysis sessions and the effective period calculated was 1.4 days, in accordance with extents of water purification in the dialyzate waste of 36.0, 14.0 and 9.4%, respectively. The extents of water purification in blood were 69.7, 47.9 and 22.7%, respectively, at the beginning of each dialysis and 37.7, 42.8 and 18.1%, respectively, at the end of each dialysis. Twenty months after the medical procedure the patient is still alive without any disease progression and always on chronic dialysis for his nephrological disease.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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The most effective non-surgical treatment for well-differentiated thyroid cancer is, beyond question, ablation with radioiodine. Other conventional modes of anti-cancer treatment such as chemotherapy or external-beam radiotherapy could be considered, but insufficient evaluation has been performed to date. The most important studies have documented that 131I decreases cancer deaths, tumor recurrence and development of distant metastases. However, the dose of 131I for ablation is not standardized: low doses (30–50 mCi) in ‘low-risk’ patients and higher ablative doses ranging from 100 to 150 mCi in older, ‘high-risk’ patients (incomplete resection of the primary tumor, an invasive primary tumor or metastases) (2,3). Moreover, the finding of thyroid cancer in a patient with renal failure undergoing routine maintenance hemodialysis represents rare cases in the international literature and, unfortunately, previous studies of isolated cases led to variable conclusions concerning which dose of radioiodine could be given to the patient (4–10). Morrish et al. (10) suggested increasing the radioiodine dosage mainly because dialysis results in rapid iodine clearance, whereas Howard and Glasser (7), Daumerie et al. (5) and Kaptein et al. (8) proposed a 4–5-fold dose reduction to avoid bone marrow toxicity and Mello et al. (9) used normal standard activity. One of the major problems consists in avoiding and controlling the side effects due to radioiodine therapy. 131I is principally eliminated by the kidneys. Therefore, when their function is altered, the side effects such as sialadenitis, nausea, temporary bone marrow suppression, dose-dependent relationship of leukemia and development of bladder carcinoma could be increased. The different conclusions drawn in the literature are probably due to the fact that hemodialyses were not performed at the same time: evaluation of the disposition of radioiodine can then vary. In the present study, the radioiodine dose was better increased within the half-life period observed (2.7 ± 0.8 h), compared with a similar treatment performed in a patient with a normal kidney function (11.4 h) (5). We therefore propose for patients on chronic dialysis to administer no more than 125% of the currently prescribed activity (activity which is dependent on the potential ‘risk’ of each patient) and to initiate the first dialysis after radioiodine administration. We conclude that dialysis results in rapid iodine clearance, thereby reducing the effective radiation dose and promoting the need for significantly larger treatment doses. The treatment procedure can be performed easily without significant radiation contamination or danger to personnel if proper precautions are observed. Moreover, it is almost impossible to perform a good dosimetry in adjuvant treatment given that physicians do not have any target to calculate the ideal dose that the patient must receive. To ameliorate this problem, statisticians could suggest optimal experiments for a Bayesian estimation of the parameters of radioiodine thyroid uptake (11).
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FOOTNOTES |
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+ For reprints and all correspondence: Nicolas Magné, Oncopharmacology Unit, Centre Antoine Lacassagne, 33 Avenue de Valombrose, 06189 Nice Cedex 2, France. E-mail: nicolas_magne@hotmail.com
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
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1 Solomon BL, Wartofsky L, Burman KD. Current trends in the management of well differentiated papillary thyroid carcinoma. J Clin Endocrinol Metab 1996;81:333–9.[Abstract]
2 Beierwaltes WH, Rabbani R, Dmuchowski C, Lloyd RV, Eyre P, Mallette S. An analysis of ‘ablation of thyroid remnants’ with I-131 in 511 patients from 1947–1984: experience at the University of Michigan. J Nucl Med 1984;25:1287–93.
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8 Kaptein EM, Levenson H, Siegel ME, Gadallah M, Akmal M. Radioiodine dosimetry in patients with end-stage renal disease receiving continuous ambulatory peritoneal dialysis therapy. J Clin Endocrinol Metab 2000;85:3058–64.
9 Mello AM, Isaacs R, Petersen J, Kronenberger S, McDougall IR. Management of thyroid papillary carcinoma with radioiodine in a patient with end stage renal disease on hemodialysis. Clin Nucl Med 1994;19:776–81.[Medline]
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Received October 15, 2001; accepted March 20, 2002
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