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Recombinant Human Thyrotropin for the Diagnosis and Treatment of a Highly Functional Metastatic Struma Ovarii*

Clinical Endocrinology Branch (P.R.-P., P.M.Y., N.J.S.) and Division of Intramural Research (M.C.S.), National Institute of Diabetes, Digestive, and Kidney Diseases, and the Nuclear Medicine Department (J.C.R., W.C.B.), Warren G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892

Address correspondence and requests for reprints to: Nicholas J. Sarlis, M.D., Ph.D., Investigator, Clinical Endocrinology Branch, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Building 10, Room 8D12C, 10 Center Drive, MSC 1758, Bethesda, Maryland 20892-1758. E-mail: njsarlis{at}helix.nih.gov

The optimal treatment of metastatic thyroid cancer that produces high amounts of thyroid hormone has not been well defined. A 46-yr-old woman presented with a follicular thyroid carcinoma arising from a struma ovarii with hepatic metastases. After the removal of both the struma and the thyroid gland, the liver metastases showed evidence of a high degree of hormonogenesis. Brain, chest, abdomen, and bone imaging was negative for additional metastases. Because iodine uptake by most thyroid carcinomas is quite low in the absence of high levels of ambient TSH, we used recombinant human TSH (rhTSH) (Thyrogen) to achieve a concentration of ¹³¹I activity in the tumor high enough for a significant cytotoxic effect. After rhTSH administration (0.9 mg im daily for 2 consecutive days), a ¹³¹I diagnostic whole body scan confirmed the existence of 17 discrete hepatic foci of ¹³¹I uptake. To calculate the amount of ¹³¹I that would deliver an absorbed radiation dose that would be optimally cytotoxic to the metastases (>8000 rad/lesion) and not to the normal liver, we performed lesion dosimetry. Analysis of dosimetric data showed that 15 of 17 lesions would receive an adequate radiation dose following the administration of 65 mCi of ¹³¹I. Additionally, we performed whole body dosimetry to assure that this dose would not cause bone marrow toxicity. The patient was reevaluated 6 months after therapy; the liver metastases showed significant, but partial, response. In conclusion, we used the combination of rhTSH with lesional and whole body dosimetry for the treatment of highly functional metastases from follicular thyroid carcinoma arising within a struma ovarii. This strategy can be applied to determine a safe and effective dose of ¹³¹I for the treatment of any thyroid cancer metastases that produce enough TH to preclude stimulation of endogenous pituitary TSH secretion.

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