Procedure guideline for radioiodine therapy and ¹³¹iodine whole-body scintigraphy in paediatric patients with differentiated thyroid cancer

Summary

The procedure guideline for radioiodine (¹³¹I) therapy and ¹³¹I whole-body scintigraphy of differentiated thyroid cancer in paediatric patients is the counterpart to the procedure guidelines (version 3) for adult patients and specify the interdisciplinary guideline for thyroid cancer of the Deutsche Krebsgesellschaft concerning the nuclear medicine part. Characteristics of thyroid cancer in children are the higher aggressiveness of papillary thyroid cancer, the higher frequency of extrathyroidal extension and of disseminated pulmonary metastases as well as the high risk of local recurrences. Radioiodine therapy is generally recommended in children, the ¹³¹I activity depends on the children's body weight. Radioiodine ablation in children with small papillary cancer (≤1 cm) should be considered. TSH stimulation is reached two weeks (children) or three weeks (adolescents) after withdrawal of thyroid hormones. Anti-emetic drugs are highly recommended. CT of the chest and examination of pulmonary function are clearly indicated if there is any suspicion on metastases. 3–6 months after ¹³¹I ablation, the ¹³¹I whole-body scintigraphy is highly recommended as lymph node metastases are frequently detected in paediatric patients. Follow-up care should be arranged in shorter intervals than in adults to test the compliance and to adapt dosage of thyroid hormones to the children's body weight. Reference values of fT3 are higher in children than in adults. Evidence is insufficient to describe in which constellation the TSH may be kept within the low normal level. Therefore, TSH suppression is generally recommended.

Zusammenfassung

Die Verfahrensanweisung zur Radioiodtherapie (RIT) und zur ¹³¹I-Ganzkörperszintigraphie beim differenzierten Schilddrüsenkarzinom im Kindes- und Jugendalter reiht sich thematisch neben die entsprechenden Verfahrensanweisungen (Version 3), die für erwachsene Patienten verfasst sind, und konkretisiert die interdisziplinäre Leitlinie der Deutschen Krebsgesellschaft um die nuklearmedizinischen Aspekte. Besonderheiten im Kindes- und Jugendalter sind die höhere Aggressivität des papillären Schilddrüsenkarzinoms, die Häufigkeit eines organüberschreitenden Tumorwachstums und einer disseminierten pulmonalen Metastasierung sowie die hohe lokale Rezidivrate. Die TNM-Klassifikation wird aufgrund der geringen Ausdehnung der normalen kindlichen Schilddrüse der Risikostratifikation nicht gerecht. Grundsätzlich besteht auch bei Kindern die Empfehlung zur Radioiodtherapie, wobei die ¹³¹I-Aktivität gewichtsabhängig appliziert wird. Bei kleinen papillären Schilddrüsenkarzinomen (≤1 cm) ist die Indikation zu einer ablativen Radioiodtherapie eher großzügig zu stellen. Nach Hormonentzug wird die TSH-Stimulation bereits nach zwei Wochen (Kinder) bzw. drei Wochen (Jugendliche) erreicht. Antiemetika werden großzügig verordnet. Die Indikation zur CT des Thorax und zur Lungenfunktionsuntersuchung ist bei Metastasenverdacht großzügig zu stellen. Auf die diagnostische ¹³¹I-Ganzkörperszintigraphie drei bis sechs Monate nach ablativer Radioiodtherapie sollte wegen der Häufigkeit einer lymphogenen Metastasierung nicht verzichtet werden. Nachsorgeintervalle sind eher kürzer zu wählen, um eine unzureichende Compliance bei Kindern frühzeitig zu erfassen und um die Hormondosis gewichtsbezogen anzupassen. Der höhere Normbereich von fT3 für Kinder ist zu beachten. Es liegt keine ausreichende Evidenz vor, ob und wann eine nicht-suppressive Einstellung der Schilddrüsenfunktion sinnvoll ist. Daher ist die TSHSuppression grundsätzlich anzustreben.

Keywords

Procedure guidelines - differentiated thyroid cancer - radioiodine therapy - paediatric patients - children - adolescents

Schlüsselwörter

Verfahrensanweisung - differenziertes Schilddrüsenkarzinom - Radioiodtherapie - Kindesalter - Jugendalter - Pädiatrie

• Literatur

• 1 Alessandri A, KJG Blair G. et al. Age is the major determinant of recurrence in pediatric differentiated thyroid carcinoma. Med Pediatr Oncol 2000; 35: 41-46.
• 2 Biermann M, Schober O. Should high hTg levels in the absence of iodine uptake be treated. Eur J Nucl Med Mol Imaging 2003; 30: 160-163.
• 3 Casara D, Rubello D, Saladini G. et al. Different features of pulmonary metastases in differentiated thyroid cancer: natural history and multivariate statistical analysis of prognostiv variables. J Nucl Med 1993; 34: 1626-1631.
• 4 Cooper D, Doherty G, Haugen B. et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006; 16: 109-142.
• 5 Corrias A, Einaudi S, Chiorboli E. et al. Accuracy of fine needle aspiration biopsy of thyroid nodules in detecting malignancy in childhood: comparison with conventional clinical, laboratory, and imaging approaches. J Clin Endocrinol Metab 2001; 86: 4644-4648.
• 6 Demidchik Y, Demidchik E, Reiners C. et al. Comprehensive clinical assessment of 740 cases of surgically treated thyroid cancer in children of Belarus. Ann Surg 2006; 243: 525-532.
• 7 Deutsche Krebsgesellschaft. Interdisziplinäre Leitlinie der Deutschen Krebsgesellschaft und der Deutschen Gesellschaft für Chirurgie. Informationszentrum für Standards in der Onkologie - IS- TO. Maligne Schilddrüsentumore. 3. Auflage 2002 (www.uni-duesseldorf.de/AWMF).
• 8 Dietlein M, Dressler J, Eschner W. et al. Verfahrensanweisung zur Radioiodtherapie (RIT) beim differenzierten Schilddrüsenkarzinom (Version 3). Nuklearmedizin 2007; 46: 213-219.
• 9 Dietlein M, Dressler J, Escher W. et al. Verfahrensanweisung für die Iod-131-Ganzkörperszintigra- phie beim differenzierten Schilddrüsenkarzinom (Version 3). Nuklearmedizin 2007; 46: 206-212.
• 10 Dietlein M, Schober O, Schicha H. über- oder Untertherapie des papillären Mikrokarzinoms der Schilddrüse? überlegungen zur ablativen Radioiodtherapie. Nuklearmedizin 2004; 43: 107-114.
• 11 Dottorini M, Vignati A, Mazzucchelli L. et al. Differentiated thyroid carcinoma in children and adolescents: a 37-year experience in 85 patients. J Nucl Med 1997; 38: 669-675.
• 12 Farahati J, Bucsky P, Parlowsky T. et al. Characteristics of differentiated thyroid carcinoma in children and adolescents with respect to age, gender, and histology. Cancer 1997; 80: 2156-2162.
• 13 Farahati J, Demidchik E, Biko J. et al. Inverse association between age and the time of radiation exposure and extent of disease in cases of radiation- induced childhood thyroid carcinoma in Belarus. Cancer 2000; 88: 1470-1476.
• 14 Farahati J, Reiners C, Demidchik E. Is the UICC/ AJCC Classification of primary tumor in childhood thyroid carcinoma valid?. J Nucl Med 1999; 40: 2125.
• 15 Fenton C, Lukes Y, Nicholson D. et al. The ret/PTC Mutations are common in sporadic papillary thyroid carcinoma of children and young adults. J Clin Endocrinol Metab 2000; 85: 1170-1175.
• 16 Hilditch T, Dempsey M, Bolster A. et al. Self-stunning in thyroid ablation: evidence from comparative studies of diagnostic ¹³¹I and 123I. Eur J Nucl Med Mol Imaging 2002; 29: 783-788.
• 17 Hung W, Sarlis N. Current controversies in the managament ofpediatric patients with well-differentiated nonmedullary thyroid cancer: a review. Thyroid 2002; 12: 683-702.
• 18 Hyer S, Vini L, O'Connell M. et al. Testicular dose and fertility in men following ¹³¹I therapy for thyroid cancer. Clinical Endocrinol 2002; 56: 755-758.
• 19 Iorcansky S, Herzovich V, Qualey R. et al. Serum thyrotropin (TSH) levels after recombinant human TSH injections in children and teenagers with papillary thyroid cancer. J Clin Endocrinol Metab 2005; 90: 6553-6555.
• 20 Jarzab B, Handkiewicw-Junak D, Wloch J. 0Juvenile differentiated thyroid carcinoma and the role of radioiodine in its treatment: a qualitative review. Endocrine-Related Cancer 2005; 12: 773-803.
• 21 Jarzab B, Handkiewicw-Junak D, Wloch J. et al. Multivariate analysis ofprognostic factors for differentiated thyrois cancer in children. Eur J Nucl Med 2000; 27: 833-841.
• 22 Krassas G, Pontikides N. Male reproductive function in relation with thyroid alterations. Best Practice Res Clin Endocrinol Metab 2004; 18: 183-195.
• 23 Kuijt W, Huang S. Children with differentiated thyroid cancer achieve adequate hyperthyrotropi- nemia within 14 days of levothyroxine withdrawal. J Clin Endocrinol Metab 2006; 90: 6123-6125.
• 24 LaQuaglia M, Black T, Holcomb GI. et al. Differentiated thyroid cancer: cilical characteristics, treatment, and outcome in patients under 21 years of age who present with distant metastases. a report from the surgical discipline committee of the children's cancer group. J Pediatr Surg 2000; 35: 955-960.
• 25 Lassmann M, Biassoni L, Monieurs M. et al. The New EANM Dosage Card. Eur J Nucl Med Mol Imaging 2007; 34: 796-798.
• 26 Leboulleux S, Baudin E, Hartl D. et al. Follicular- cell drived thyroid cancer in children. Eur J Cancer 2004; 40: 1655-1659.
• 27 Machans A, Holzhausen H, Dralle H. The prognostic value of primary size in papillary and folicular thyroid carcinoma. Cancer 2005; 103: 2269-2273.
• 28 Musholt T, Musholt P, Petrich T. et al. Familiar papillary thyroid carcinoma: genetics, criteria for diagnosis, clinical features, and surgical treatment. World J Surg 2000; 24: 1409-1417.
• 29 Nakada K, Ishibashi T, Takei T. et al. Does lemon candy decrease salivary gland damage after radio-iodine therapy for thyroid cancer?. J Nucl Med 2005; 46: 261-266.
• 30 Newman K, Black T, Heller G. et al. Differentiated thyrois cancer: determination of disease progression in patients <21 years of age at diagnosis: a report from the surgical discipline committee of the children's cancer group. Ann Surg 1998; 227: 533-541.
• 31 Pacini F, Gasperi M, Fugazzola L. et al. Testicular function in patients with differentiated thyroid carcinoma treated with radioiodine. J Nucl Med 1994; 35: 1418-1422.
• 32 Pacini F, Schlumberger M, Dralle H. et al. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur JEndocrin 2006; 154: 787-803.
• 33 Pacini F, Vorontsova T, Demidchik E. et al. Post- Chernobyl thyroid carcinoma in Belarus children and adolescents: comparison with naturally occu- ring thyroid carcinoma in Italy and France. J Clin Endocrinol Metab 1007; 82: 3563-3569.
• 34 Pelizzo M, Boschin I, Toniato A. et al. Natural history, diagnosis, treatment and outcome ofpapilla- ry thyroid microcarcinoma (PTMC): a onoins- titutional 12-year experience. Nucl Med Communs 2004; 25: 547-552.
• 35 Reiners C. Das kindliche Schilddrüsenkarzinom. In: Diagnostik, Therapie und Nachsorge des Schilddrüsenkarzinoms. Reiners C. (ed). 2. Auflage ed Bremen: Unimed; 2006: 102-112.
• 36 Reiners C, Lassmann M, Hänscheid H. A perspective on post-Chernobyl radioablation in young females. J Nucl Med 2006; 47: 1563-1564.
• 37 Ringel M, Levine M. Current therapy for childhood thyroid cancer: optimal surgery and the legacy of king pyrrhus. Ann Surg Oncol 2003; 10: s4-6.
• 38 Robbins R, Tuttle R, Sharaf R. et al. Preparationby recombinant human thyreotropin or horman with- drawel are comparable for the detection of residual differentiated thyroid carcinoma. J Clin Endocrinol Metab 2001; 86: 619-625.
• 39 Samaan N, Schultz P, Hickey R. et al. The results of various modalities of treatment of well differentiated thyroid carcinoma: aretrospective review of 1599 patients. J Clin Endocrinol Metab 1992; 75: 714-720.
• 40 Samuel A, Rajashekharrao B, Shah D. Pulmonary metastases in children and adolescents with well-differentiated thyroid cancer. J Nucl Med 1998; 39: 1531-1536.
• 41 Schlumberger M, De athaire F, Ceccarelli C. et al. Exposure to radioactive iodine-131 for scintigraphy or therapy does not prclude pregnancy in thyroid cancer patients. JNucl Med 1996; 37: 612-615.
• 42 Thompson G, Hay I. Current strategies for surgical management and adjuvant treatment of childhood papillary thyroid carcinoma. World J Surg 2004; 28: 1187-1198.
• 43 van Tol K, Jager P, Piers D. et al. Better yield of (18)fluorodeoxyglucose-positron emission tomography in patients with metastatic differentiated thyroid carcinoma during thyrotropin stimulation. Thyroid 2002; 12: 381-387.
• 44 Wichers M, Benz E, Palmedo H. et al. Testicular function after radioiodine therapy for thyroid carcinoma. Eur J Nucl Med 2000; 27: 503-507.