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Endocrine Care |
Department of Endocrinology and Metabolism, Section of Endocrinology, University of Pisa, 56124 Pisa, Italy
Address all correspondence and requests for reprints to: Dr. F. Pacini, Department of Endocrinology and Metabolism, Section of Endocrinology, University of Pisa, Via Paradise, 2-56124 Pisa, Italy.
Abstract
Detectable serum Tg levels associated with negative diagnostic 131I whole body scan are not infrequently found in patients with differentiated thyroid cancer. Several researchers have shown that in these patients the administration of high 131I activity (100 mCi or more) increases the sensitivity of a posttherapy diagnostic 131I whole body scan performed a few days later and allows the detection of neoplastic foci not seen with diagnostic doses of 131I. Empirical radioiodine treatment has also been advocated by some researchers, but its therapeutic effect is controversial.
In our institute, positive serum Tg/negative diagnostic 131I whole body scan patients were not treated with high 131I activities before 1984; afterward, almost all patients with positive serum Tg/negative diagnostic 131I whole body scan patients were treated with radioiodine, and a posttherapy diagnostic 131I whole body scan was performed. In the present retrospective study we compared the outcome of these two groups of patients, 42 treated and 28 untreated, followed for mean periods of 6.7 ± 3.8 and 11.9 ± 4.4 yr, respectively. In the treated group the first posttherapy diagnostic 131I whole body scan was negative in 12 patients and positive in 30 patients. 131I treatment was further administered only in the latter group.
At the end of follow-up in treated patients a complete remission (normalization of serum Tg off L-thyroxine and negative diagnostic 131I whole body scan) was observed in 10 patients (33.3%). In 9 cases (30%) posttherapy diagnostic 131I whole body scan became negative, and serum Tg was reduced but still detectable; in 11 patients (36.6%) serum Tg was detectable, and posttherapy diagnostic 131I whole body scan was positive. The resolution of 131I uptake in lung metastases was observed in 8 of 9 cases (88.8%) and in cervical node metastases in 11 of 18 cases (61.1%). In patients treated only once because the posttherapy diagnostic 131I whole body scan was negative (n = 12), 2 patients (16.7%) were in apparent remission, 7 (58.3%) had detectable Tg values without evidence of disease, 2 (16.7%) showed lymph node metastases in the mediastinum, and 1 patient (8.3%) died because of lung metastases.
Of the 28 untreated patients, none with radiological evidence of disease, serum Tg off L-thyroxine therapy became undetectable in 19 cases (67.9%), significantly reduced in 6 cases (21.4%), and unchanged or increased in 3 patients (10.7%), 1 of whom developed lung metastases 14 yr after the diagnosis.
In summary, our results indicate that in patients with detectable serum Tg and negative diagnostic 131I whole body scan, treatment with high doses of 131I may have therapeutic utility in patients with lung metastases and, to a lesser extent, in those with lymph node metastases. However, in view of the frequent normalization of Tg values in untreated patients, we believe that treatment with 131I should be considered according to the result of the first posttherapy scan. If positive in the lung, 131I treatment should be continued up to total remission; surgical treatment should be preferred in patients with node metastases, and no treatment should be used in those with thyroid bed uptake or no uptake.
SERUM Tg LEVELS off L-thyroxine therapy are usually well correlated with the results of diagnostic 131I whole body scan (WBS) in the postsurgical follow-up of differentiated thyroid cancer. Undetectable Tg levels are found in patients with WBS-, suggesting complete remission, whereas detectable or elevated Tg concentrations are associated with the presence of 131I uptake in local or distant metastases (1, 2, 3, 4, 5, 6).
Several large series have shown that in 10–15% of the patients detectable serum Tg levels are found despite WBS- (4, 7, 8). In these cases, the discrepancy is mainly due to metastases able to produce Tg but having iodine uptake too low to be visualized on diagnostic scans, either because the mechanism of iodine trapping is defective or because the mass of neoplastic tissue is small. In this situation several researchers (8, 9, 10) have shown that the administration of high 131I activity (100 mCi or more) increases the sensitivity of a WBS performed a few days later and allows the detection of neoplastic foci not seen with diagnostic doses of 131I.
Evidence of therapeutic effect with this treatment modality has been provided by some researchers (8, 10), but its impact on the final outcome of the disease remains uncertain, mainly due to the lack of long-term controlled studies including patients left untreated.
In our institution, positive serum Tg (Tg+)/WBS- patients were not treated with high 131I doses before 1984. Afterward, almost all patients with Tg+/WBS- were treated with radioiodine based on our initial finding that this procedure was beneficial (9). We report here the comparison of these two groups of patients, treated and untreated, with regard to the behavior of serum Tg and the long-term outcome of the disease. We are aware that the study is not randomized, but the two groups are unselected, and we believe that the study may give new insight into the controversial issue of the management of Tg+/WBS- patients.
Subjects and Methods
Patients
Seventy patients affected by papillary differentiated thyroid cancer (52 females and 18 males), aged 14–75 yr, were suitable for this study. All patients had been treated with near-total thyroidectomy during 1969 to 1995, followed by thyroid ablation with 131I therapy. Thyroid ablation was preceded by a diagnostic WBS, and a posttherapy WBS was not routinely performed. Serum Tg measurement was an integral part of the follow-up. The first Tg measurement was obtained 3–4 months after thyroidectomy and subsequently at any clinical control on L-thyroxine therapy and off L-thyroxine any time the patient was scheduled for WBS.
At some point of the subsequent follow-up (1–22 yr after initial treatment; mean, 4.0 ± 3.8 yr), always after thyroid ablation, these patients showed detectable/elevated serum Tg values off L-thyroxine in the absence of circulating anti-Tg autoantibodies (AbTg), and negative diagnostic WBS performed with a tracer dose of 5 mCi of 131I. This eventuality was mainly observed during the first year after initial treatment (probably representing persistent disease) and only sporadically during follow-up after a period of time with undetectable serum Tg levels (probably representing recurrence of disease after a disease-free interval). No clinical or radiological evidence of local or distant disease [by ultrasound, chest x-ray, and lung computed tomography (CT) scan] was documented. Other patients, with radiological evidence of local or distant metastases, were assigned to appropriate treatment and were not included in this series. Circulating TSH measurement and urinary iodine excretion were used to rule out a mistake in withdrawing L-thyroxine therapy or iodine contamination as the cause of negative WBS.
Twenty-eight (40%) of the 70 patients, seen before 1984, were not treated with therapeutic doses of radioiodine. The other 42 (60%) patients, seen after 1984, were treated with at least 1 therapeutic dose of 131I (90–150 mCi), followed by posttherapy WBS. This posttherapy WBS was negative in 12 and positive in 30 patients. The therapeutic procedure was not repeated in the 12 negative patients, whereas further 131I treatments and posttherapy WBS were performed in positive patients. The procedure was discontinued when serum Tg off L-thyroxine became undetectable or when the posttherapy scan was negative, even if serum Tg was still detectable. In summary we have a group of 28 Tg+/WBS- patients never treated with high 131I doses (untreated group), a group of 30 patients submitted to several treatment courses of radioiodine (treated group), and a group of 12 patients treated only once because the posttherapy scan was negative.
The epidemiological and clinical data of the study groups are shown in
Table 1
. Among the 42 patients treated
with 131I (32 women and 10 men; mean age,
39.1 ± 15.7 yr; range, 14–75 yr), the tumor stage at the time of
diagnosis according to the Tumor-Node-Metastases classification
(11) was stage 1 in 6 patients (14.3%), stage 2 in 24
(57.1%), and stage 3 in 10 (23.8%); in 2 (4.8%) patients it was not
possible to ascertain the stage. Among 28 patients not subjected to
131I treatment (20 women and 8 men; mean age,
37.3 ± 12.4 yr; range, 14–60 yr), 11 (39.3%) patients had stage
1, 10 (35.7%) had stage 2, and 7 (25.0%) had stage 3 disease. The
postsurgical 131I ablation dose was not different
in treated or untreated patients (67.5 ± 33.9 and 69.7 ±
30.2 mCi, respectively).
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131I WBS
Total body scan was performed using a rectilinear scanner. In
all cases the conventional WBS was performed 48–72 h after
administration of a tracer dose of 5 mCi 131I.
The time of scan was correlated with the activity expressed in counts
per sec (cps) and ranged between 50–150 min. Scan speed was 50
cpm for 200 cps or less and 150 cpm for 200–500 cps. For more than 500
cps the scan speed was 200 cpm. Since 1995 a one-head 
-camera
(Apex SPX 4000, Elscint Italia, Milano, Italy) was used, with a
high energy collimator and a sensitivity of 160 cpm/µCi. The scan
speed was 10 cm/min, with total counts of at least 100,000 cpm. WBS
after therapeutic doses of 131I (90–150 mCi) was
performed 5–10 d after administration of the dose.
As the empirical treatment with 131I reported in
this study started in 1984, most patients were studied with the same
apparatus (rectilinear scanner). Only a minority of the scans were
performed with the more sensitive -camera introduced in 1995.
Measurement of serum Tg
Starting in 1974, serum Tg became a routine test in thyroid cancer patients. Serum Tg was measured by home-made RIA, with a functional sensitivity of 1.5 ng/ml, up to 1980 and by commercial immunoradiometric assay (HTGK, Sorin Biomedica, Saluggia, Italy), with a functional sensitivity of 3 ng/ml, after 1980. These cut-off values correlated well with remission or persistence of disease (12). As circulating AbTg interfere in Tg assays producing false results, we routinely screen all patients for serum AbTg by passive hemagglutination (Thyroid Test Kit, Fujizaki, Pharmaceutical Co., Tokyo, Japan) (13). Patients with positive autoantibodies were not included in this analysis.
Statistics
The Mann-Whitney U test was used for the analysis of serum Tg in
different groups. The 
2 test was used for the
analysis of epidemiological and clinical features of different groups.
P < 0.05 was considered significant.
Results
Serum Tg at the first evidence of detectable Tg values and negative diagnostic WBS
As shown in Table 2, mean serum Tg
values off L-thyroxine therapy were 62.1 ± 44.1
ng/ml (range, 7–207 ng/ml) in treated patients and 39.7 ± 54
ng/ml (range, 4–195 ng/ml) in untreated patients (P =
0.003, by Mann-Whitney U test). During
L-T4 suppressive therapy,
Tg values were detectable in 12 of 30 treated patients (mean, 14.9
± 12.9 ng/ml; range, 4 -38 ng/ml) and undetectable (<3 ng/ml) in the
other 18 cases. In untreated patients Tg values were detectable in 4 of
28 cases (mean, 11.2 ± 8.5 ng/ml; range, 3–22 ng/ml).
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After administration of a therapeutic dose of
131I (90–150 mCi) areas of radioiodine uptake in
the posttherapy scan were present in 30 cases (Fig. 1): thyroid bed in 3 cases (10%),
cervical nodes in 18 cases (60%), and lung with or without cervical
nodes in 9 cases (30%). Posttherapy WBS was negative in 12 patients.
These 12 patients were no longer treated with radioiodine. The
relationship between the results of the posttherapy WBS and the
individual values of serum Tg both off and on
L-thyroxine is shown in Fig. 2.
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The mean period of follow-up in this group was 6.7 ± 3.8 yr; during this period the patients were subjected to further radioiodine treatment, posttherapy WBS, and serum Tg measurement both off and on L-thyroxine therapy.
As shown in Fig. 3, patients were treated
with cumulative 131I doses ranging between
90–500 mCi (mean, 256.8 ± 117.9 mCi). The mean number of
radioiodine courses was 3 (range, 1–6). As summarized in Table 3, at the end of follow-up, the
normalization of serum Tg off L-thyroxine (Tg
undetectable) with negative WBS was observed in 10 patients (33.3%),
including 1 patient with thyroid residue, 6 patients with lymph node
metastases, and 3 patients with lung metastases at the time of the
first posttherapy scan. The normalization of posttherapy WBS was
observed in 9 patients (30%) in whom serum Tg was still detectable
although reduced; in 11 patients (36.6%) both serum Tg and posttherapy
WBS were abnormal, with evidence of radioiodine uptake in cervical
nodes (9 cases) and in the lungs (2 cases). The individual changes in
serum Tg off L-thyroxine at the end of follow-up with
respect to initial values are depicted in Fig. 4. Together, the normalization of serum
Tg off L-thyroxine or the disappearance of uptake was
observed in 8 of 9 patients (88.8%) with lung metastases and in 11 of
18 (61.1%) with cervical node metastases.
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In this group the mean period of follow-up was 11.9 ± 4.4
yr. Patients were assessed by serum Tg measurement, diagnostic WBS, and
radiological evaluation (neck ultrasonography, chest x-ray, CT scan, or
NMR). At the end of the study serum Tg off L-thyroxine
therapy was undetectable in 19 cases (67.9%), significantly reduced in
6 cases (21.4%), and unchanged or increased in 3 cases (10.7%). As
shown in Table 4, these data were further
analyzed, subdividing the 28 patients into 2 groups according to the
initial Tg values (>10 ng/ml, 14 patients; 
10 ng/ml, 14 patients).
In those with Tg levels greater than 10 ng/ml, the last control Tg
became undetectable in 7 cases (50%), decreased in 6 cases (42.9%),
and increased in 1 case (7.1%). In patients with Tg levels of 10 ng/ml
or less, the last control Tg became undetectable in 12 cases (85.7%)
and unchanged or increased in 2 cases (14.3%). Lung macrometastases
were discovered in 1 of these patients by CT scan, 14 yr after
diagnosis. Diagnostic WBS remained negative in all patients.
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In this cohort of patients with negative posttherapy WBS at the
time of the first radioiodine treatment, the mean period of follow-up
was 6.5 ± 3.7 yr. At the end of follow-up, 2 patients (16.7%)
were in apparent remission (undetectable Tg and no evidence of
disease), 7 (58.3%) had detectable serum Tg concentrations without
evidence of disease, 2 (16.7%) had evidence of lymph node metastases
in the mediastinum detected by CT scan, and 1 patient (8.3%) developed
lung metastases, which caused her death (Table 5).
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Serum Tg levels are usually undetectable in patients without residual disease during the postsurgical follow-up of differentiated thyroid carcinoma. On the contrary, the finding of detectable/elevated serum Tg levels is the most reliable evidence of persistent or recurrent disease (7, 12, 14).
Serum Tg levels are usually well correlated with the results of WBS; however, in some cases serum Tg levels may be found in patients with no evidence of residual or metastatic thyroid tissue, including negative diagnostic WBS. Several large series have found this discrepancy in 10–15% of patients (4, 7, 8). In particular, some studies (8, 9, 10, 15) have clearly shown that the administration of high 131I activity (100 mCi or more) increases the sensitivity of a posttherapy WBS and allows the detection of neoplastic foci not seen with diagnostic doses of 131I. The therapeutic effect of this treatment is not fully demonstrated and is sometimes questioned.
In our study we addressed this issue by reviewing the outcome of two groups of patients with Tg+/WBS-, one of whom was treated with high 131I activities and one who was left untreated.
From the diagnostic point of view, our results show the high sensitivity of posttherapy 131I WBS in Tg+/WBS- patients. Visible uptake limited to the thyroid bed occurred in a minority of cases (three patients) and was interpreted as persistent thyroid residue. Its association with detectable serum Tg off L-thyroxine should not be surprising, especially if persistent residual thyroid tissue is abundant and TSH stimulation is important, as in our cases. From the clinical point of view, we believe that these residues do not represent a matter of concern for the patients’ outcome and probably should not be treated with additional doses of radioiodine. Support for this hypothesis has been provided by Cailleux et al. (16), who in addition showed that metastatic disease may be discovered by scanning the patients after they received the ablative dose. However, the possibility that thyroid bed uptake may be due to residual or recurrent tumor rather than to normal thyroidal tissue should always be considered.
Our results indicate that the administration of a high 131I dose in Tg+/WBS- patients is effective in curing lung metastases and, to a lesser extent, lymph node metastases. At the end of the follow-up, lymph node metastases were cured in 11 of 18 cases (61.1%). The complete resolution of 131I uptake in lung metastases was observed in 8 of 9 cases (88.8%), associated with serum Tg normalization in 3 cases and with serum Tg decline in the others. In these cases we cannot prove that the resolution of 131I uptake demonstrates effective treatment rather than loss of iodine-trapping ability. We favor the first possibility based on the consideration that our cases of lung metastases were all of the micronodular diffuse type, not visible on chest x-ray, those usually reported as having the best prognosis after radioiodine treatment. Furthermore, in one case the resolution of 131I uptake correlated with the results of CT scan, which converted to negative after treatment. In the other cases, the CT scan was negative from the beginning.
Similar results have been reported in previous studies (8, 10, 17). Schlumberger et al. (8) showed the complete remission of lung metastases demonstrated by posttherapy WBS in 20 of 23 patients with differentiated thyroid carcinoma when chest x-ray was normal. Pineda et al. (10) reported therapeutic effectiveness of 131I treatment in 14 patients with elevated Tg and negative WBS as assessed by a significant reduction of serum Tg to 5 ng/ml or less and by normalization of previously positive posttherapy WBS. Fautorechi et al. (17) concluded that treatment with high doses of 131I in Tg+/WBS- patients, allows the detection of abnormal uptake in posttherapy WBS, particularly micrometastases. In their experience aggressive macrometastases with negative diagnostic WBS do not show significant uptake after therapeutic doses of 131I.
Despite the above reports, the use of high 131I activities in Tg+/WBS- patients has been questioned by some researchers, mainly due to the lack of control studies (18, 19).
Although retrospective and not randomized, our study included a control group of untreated Tg+/WBS- patients. The outcome of this group was good. Serum Tg dropped to undetectable levels in nearly two thirds of the patients and decreased in the others, and no evidence of disease has been documented in all but one who developed lung metastases 14 yr after the diagnosis. However, as a posttherapy scan was never performed in this group, we cannot exclude the possibility that other patients might have also had lung micrometastases that never progressed to the clinical stage. This event probably occurred in the above-mentioned patient who developed lung macrometastases and in one patient in the group treated only once who died of lung disease.
A possible comment regarding the spontaneous drop of serum Tg in untreated patients is that they might have less severe disease as the source of serum Tg: residual thyroid tissue rather than metastases. This possibility is in agreement with the observation that mean serum Tg levels off L-thyroxine therapy in the untreated group at the beginning of the study were significantly lower than those in treated patients. The spontaneous reduction of serum Tg in these patients might be due to the long-term effect of L-thyroxine suppressive therapy. Together, the above considerations suggest strict selection criteria in deciding which patients should be treated with 131I to effectively treat tumor cells and not a mathematical number of Tg.
The following protocol (Fig. 5)
seems to us a rational proposal for the management of
Tg+/WBS- patients. Each
patient presenting with
Tg+/WBS- should undergo
one treatment with high doses of 131I, followed
by posttherapy WBS. If posttherapy WBS is positive for lymph node
metastases, two alternatives, both effective, may be considered:
surgery, possibly using the surgical probe-guided approach suggested by
Travagli et al. (20) or repeated administration
of 131I therapy. If lung metastases are detected,
radioiodine treatment should be continued until complete remission,
defined as normalization of serum Tg off L-thyroxine
and/or normalization of the posttherapy scan. Thyroid uptake in the
thyroid bed should not be treated.
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Acknowledgments
Footnotes
This work was supported in part by grants from Associazione Italiana Ricerca sul Cancro, European Communities INCO-Copernicus Project IC15-CT980134, Ministero dell’Università della Ricerca Scientifica e Tecnologica 1998, and Consiglio Nazionale delle Ricerche (98.00093.PF31).
Abbreviations: AbTg, Anti-Tg autoantibodies; cps, counts per sec; CT, computed tomography; NMR, nuclear magnetic resonance; Tg+, detectable serum Tg levels; WBS-, negative diagnostic 131I whole body scan.
Received December 20, 2000.
Accepted May 15, 2001.
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