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55yr,Female,postmenopausal,KPS=70,No co-morbidities
Swelling with bleeding ulceration of the overlyig skin in the central neck region
Swelling in the neck since 4 yrs
Bleeding ulcer since 1 month
Outside FNAC report suggestive of pappilary carcinoma thyroid
PREOP TFT
FT3 = 2.85 PG/ML
FT4 = 1.12 NG/DL
TSH = 3.315 UIU/ML
Was taken up for emergengy OT
Underwent Total thyroidectomy + Central Neck Dissection + Left Level II-V lymph node dissection
Postop HPR
Well differentiated Papillary carcinoma thyroid
pT= 5x4.8x3cms
Tumor was seen extending close to the surgical margin
Skin shows evidence of ulceration, Psamomma bodies evident
Capsular invasion - POSITIVE
Lymph vessel invasion - POSITIVE
Vascular Invasion - NEGATIVE
Extrathyroidal extension POSITIVE - OVERLYING SOFT TISSUE AND SKIN
Margins - NEGATIVE
Tumor multicentricity - POSITIVE
Central compartment lymph nodes = 6/8 LN POSITIVE
Rt paratracheal LN = 0/10 LN POSITIVE
Lt PAratracheal LN= 4/8 LN POSITIVE
LT Level II-V LN = 4/13 LN POSITIVE with some LN showing Extranodal spread
SCM muscle - NEGATIVE
Shaved Tracheal Ring = POSITIVE for tumor with overlying soft tissue implants
**POSTOPERATIVE RAI WBS*
DONE AFTER FOUR WEEKS OF SURGERY SHOWED =
Increased I-131 tracer concentration evident in the thyroid bed
No other abnormal radiotracer concentration is seen in the body
POSTOP TFT = AFTER 4 WKS OF sx
THYROGLOBULIN = 249 NG/ML
ATG= 109.9 IU/ML
AMA =8.30 U/ML
The bone of contention is radioiodine ablation (High dose or Low dose) versus EBRT or it requires a combination of both
Hi Chendil,
Does your patient have lung mets by any chance? The reason why Iam asking is we use >150 mCi only in florid lung mets case.
http://tech.snmjournals.org/cgi/content/full/30/4/165
http://www.mythyroid.com/radioactiveiodinecancer.html
http://annonc.oxfordjournals.org/content/21/suppl_5/v214.full
Arun is right EBRT 66 gy to (high risk region only) is a good dose.
Extra-thyroidal spread is a definite indication for post-op Radiotherapy. The ideal sequencing being High dose (200mCi ideally)- radio iodine ablation (with D7 WBS) followed by radiotherapy.
RaI delivers 80-120 Gy to nodal/soft tissues, and 300 Gy to thyroid remnant.
Radiotherapy prior to RaI can lead to some amount of "stunning" (akin to the deleterious effect of low dose scan prior to RaI treatment), hence RaI first.
The counter point is EBRT initially leads to hyperemia in the irradiated parts for subsequent 2-6 weeks and hence RaI later may lead to improved delivery of I-131 to the neck.
Both are theoritcal possibilities — no hard data for back-up. The general consensus being RaI first.
Now the issue of delaying EBRT.
In the ideal scenario - Surgery —> RaI within 6 wks (using rTSH) followed by PORT after 2 weeks. Since the growth kinetics of PAP Ca thyroid is considered slower than Squam Cell Ca… I guess we can delay the EBRT, in the less than ideal setups.
RT dose of atleast 60 Gy to the high risk area.. preferably 66Gy @ 2Gy/#
Lots of poor prognostic factors. I would give Iodine 131 first (high dose max 150 mci, if you choose to give 100 mci is also fine) and then follow it up with EBRT (50Gy/25#'s).
http://www.ncbi.nlm.nih.gov/pubmed/21048835
http://www.ncbi.nlm.nih.gov/pubmed/20659341
http://www.hkcr.org/publ/Journal/vol8no3/full/127-135%20Side.pdf
After EBRT, keep following with throglobulin and if needed Thyrogen stimulated scan.
The bone of contention is radioiodine ablation (High dose or Low dose) versus EBRT or it requires a combination of both
Radio-iodine Ablation = Low dose vs High Dose . Does the dose matter if both modalities are needed
EBRT = COBALT vs 3D-CRT/IMRT . What if only Tele-cobalt is the only EBRT modality patient can afford vis-a-vis if any effect on local control/toxicity b/w the two EBRT modalities?
If both required sequencing of the two modalities??
Follow-up investigations ??
Hi Chendil,
Iam a bit confused here, didn't quite understand what site are we talking about.
Hi Nikhilesh read the excellent case capsule he has given here http://www.isocentre.org/headneck:radioiodine-ablation-vs-ebrt-or-both