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Treatment of Scan-Negative, Thyroglobulin-Positive Metastatic Thyroid Cancer Using Radioiodine ¹³¹I and Recombinant Human Thyroid Stimulating Hormone—Authors’ Response^h

Montefiore Medical Center and The Albert Einstein College of Medicine of Yeshiva University Bronx, New York 10467

We appreciate the opportunity to respond to the letter written by Drs. Lukinac, Franceschi, and Kusic. At the time of the first post-therapy ¹³¹I whole body scan (WBS), the patient’s thyroglobulin was 38.0 ng/mL, and his TSH was 28.6 mu/mL. In our institution, as in many others, elevation of TSH above 25 mu/mL is considered adequate for performing a valid WBS. In December 1992, while off thyroid replacement medication for several weeks in preparation for a WBS, the patient developed a palpable, movable infracervical mass below the suprasternal notch (as noted in the case report); this mass proved to be metastatic well-differentiated "pure papillary carcinoma." The sudden appearance and rapid growth of this mass, temporally related to the discontinuation of suppressive doses of thyroid medication, attests to the adequacy of TSH stimulation for the WBS. Thyroglobulin values obtained while the patient was on TSH suppressive dose of levothyroxine in June 1989, January and November 1990, June 1991, and May and November 1992 were 28.0, 30.0, 19.9, 30.0, 36.5, and 43.5 ng/mL, respectively. Thyroglobulin values obtained when thyroid medication had been discontinued for several weeks in preparation for a WBS (when the TSH was significantly elevated) in November 1989, June 1990, and January and October 1991, were 38.0, 28.3, 28.1, and 38.6 ng/mL, respectively. These values were omitted from the original report in the interest of brevity. The normal range for thyroglobulin levels was provided for information only and was not meant to imply that these levels are expected or desirable in patients following total thyroidectomy. An absolute cut-off value for thyroglobulin in patients with thyroid cancer is not as important as the trend of serial determinations in assessing the presence and spread of metastases of thyroid cancer. The patient had known metastatic disease, demonstrated on plain x-rays, computed tomography, magnetic resonance imaging, conventional nuclear bone scans, and physical examination. Studies utilizing ultrasound, ²⁰¹TI, ^99mTc sestamibi, or detection of endogenously labeled thyroid hormones (1) (an investigational procedure) would not have yielded additional clinically useful information and would not have been justified in the current environment of mandated cost-containment and cost effectiveness. Our paper was a retrospective clinical case report relating our experience with a single patient rather than a prospective multisubject clinical research study adhering to a predetermined protocol. We endeavored to afford our patient the maximum benefit with minimal pain and discomfort.

Footnotes

Received September 19, 1997. Address correspondence to: Amiel Z. Rudavsky, Department of Nuclear Medicine, Montefiore Medical Center, Bronx, New York 10467.

References

1. Bianchi R, Iervasi G, Matteucci F, et al. 1993 Chromatographic identification in serum of endogenously radioiodinated thyroid hormones after iodine-131 whole-body scintigraphy in the follow-up of patients with differentiated thyroid carcinoma. J Nucl Med. 34:2032–2037.[Abstract/Free Full Text]

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