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Levothyroxine Suppression of Thyroglobulin in Patients with Differentiated Thyroid Carcinoma¹

Departments of Internal Medicine (P.W.W., R.T.L., W.Y.C., S.C.T., Y.C.L.) and Nuclear Medicine (H.Y.C., C.H.L.), Chang Gung Memorial Hospital, Kaohsiung; and Department of Public Health, National Cheng Kung University Medical Center (S.T.W.), Tainan, Taiwan, Republic of China

Address all correspondence and requests for reprints to: Dr. Pei-Wen Wang, Department of Internal Medicine, Chang Gung Memorial Hospital, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 83305, Taiwan, Republic of China. E-mail: jhc1997{at}ms18.hinet.net

For patients with differentiated thyroid carcinoma, the appropriate degree of TSH suppression by levothyroxine (L-T₄) is still unknown. To find the target level of TSH suppression, we analyzed the relationship between the degree of TSH suppression determined by third generation assay and thyroglobulin (Tg) response during the titration of the dosage of L-T₄. Ninety-two patients with differentiated thyroid carcinoma (19 males and 73 females; age, 40.5 ± 13.5, mean ± SD) were included. All of the recruited patients had near-total thyroidectomy, 30–150 mCi ¹³¹I thyroid ablation, and negative Tg autoantibodies. They were classified into 3 groups. Group A was composed of 25 patients with local or distant relapse. Group B was composed of 12 patients without clinically detectable relapse, but Tg levels either above 2 ng/mL under L-T₄ suppression or above 3 ng/mL off L-T₄ therapy. Group C included 55 patients who had no active disease and Tg levels below 2 and 3 ng/mL during and off L-T₄ suppression, respectively. Serum TSH and Tg were measured simultaneously at the end of 8–12 weeks of a certain dose of L-T₄ therapy during dosage titration and also after withdrawal of L-T₄ for 4–6 weeks for the total body scan. Wilcoxon signed ranks test was used to compare paired samples of Tg, and Spearman rank correlation was used to determine the correlation of relative changes in TSH to changes in Tg calculated by individual. The results showed that 1) Tg levels were significantly higher during the period off L-T₄ therapy than on L-T₄ therapy in all 3 groups (P < 0.01); 2) during L-T₄ therapy, within the same treatment course, mean Tg levels were higher when TSH levels were normal than when TSH levels were suppressed, statistically significant in group A (P = 0.001), nonsignificant in group B (P = 0.09), and nonsignificant in group C (P = 0.30); and 3) when TSH was suppressed below normal, there was no correlation between the relative changes in TSH and Tg by individual in all 3 groups (P > 0.05). The data suggest a stratified postoperative thyroid hormone management of patients with differentiated thyroid carcinoma. TSH should be lowered to below normal in patients with active disease. If patients are clinically disease free with Tg levels below 2 ng/mL, TSH can be kept within the normal range. For the most controversial group B patients, it is recommended that the TSH be suppressed and be closely followed up.

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