The Role of Radiology

and Radiotherapy in
Thyroid Nodule and
Thyroid Cancer
Rima Novirianthy, MD, Rad.Onc
Radiology Department
Faculty of Medicine, Syiah Kuala University
Zainoel Abidin Hospital
 Overview
• Radiodiagnostic of thyroid nodule dan thyroid
cancer
• RAI ablation
• Radiotherapy for Thyroid Cancer
• Take home message
Radiodiagnostic of
Thyroid Nodule
and Thyroid Cancer
• Radiology modality :
– Ultrasound
– CT scan
– MRI
– Radioactive Iodine Scanning
 1. Ultrasound
2. Radioiodine Imaging
 Ultrasound
• Thyroid sonography with survey of the cervical lymph
nodes should be performed in all patients with known or
suspected thyroid nodules. (>1cm) ”strong recommendation, High-
quality evidence)” …….
• Should evaluate:
– thyroid parenchyma (homogeneous or heterogeneous)
– gland size; size, location,
– characteristics of nodule(s);
– the presence or absence of any suspicious cervical lymph
nodes in the central or lateral compartments.
2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
 Radionuclide Thyroid scan
• When we need it?
– clinically or incidentally discovered thyroid nodules
• TSH is subnormal  a radionuclide (preferably I-
123) thyroid scan should be performed.
• hyperfunctioning (‘‘hot”)
• isofunctioning (‘‘warm’’)
• nonfunctioning (‘‘cold’’)
• TSH is normal or elevated  a radionuclide scan
should not be performed as the initial imaging
evaluation. (Strong recommendation, Moderate-
quality evidence)

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
 RAI Ablation
• When we need it?
• Goals:
1. RAI remnant ablation
 the destruction of this remnant thyroid tissue with the
administration of radioactive iodine
 eliminating residual thyroid tissue, as well as microscopic
disease (intermediate risk)
2. RAI adjuvant therapy
 to improve disease-free survival unproven residual disease
 RAI adjuvant therapy is routinely recommended after total
thyroidectomy for high risk DTC patients (Strong recommendation,
Moderate-quality evidence)
3. RAI therapy
 to improve disease-specific and disease-free survival
 persistent disease in higher risk patients
2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer
RRA
• Multicentre studies  RRA significantly decreased risk of locoregional recurrence and
distant metastases
• Not routinely recommended after lobectomy or total thyroidectomy for low risk DTC
– unifocal papillary microcarcinoma, in the absence of other adverse features.
(Strong recommendation, Moderate-quality evidence)
• Cooper et all, NTCTCSG prospective cohort study  RRA was a significant predictor of
disease progression for PTC patients, sub group analysis  intermediate risk

Intermediate
risk DTC
RAI adjuvant therapy should be considered after total
thyroidectomy in ATA intermediate-risk level DTC
patients.
(Weak recommendation, Low-quality evidence)

Intermediate
risk DTC
RAI Adjuvant therapy

High risk DTC

 Appropriateness Criteria Committee
(ACR – Head and neck)
• Indications for postoperative adjuvant :
1. tumor >1–1.5 cm;
2. patient age > 45 years;
3. capsular, vascular, or softtissue invasion;
4. multifocal, residual, or recurrent disease;
5. lymph node metastasis;
6. distant metastasis;
7. Intermediate or high-risk disease based on a prognostic
system.
• Administered 4–12 weeks after thyroidectomy.
• RAI without a known residual disease can ablate the
microscopic local or distant disease.
 Effect of RAI

• The main side effect : transient hypothyroidism, unless rhTSH is

• Possible early effects :
– Abnormality of taste and sialadenitis  good hydration.
– Nausea  antiemetics.
– Neck discomfort and swelling (large thyroid remnant)  analgesic,
steroid
– Radiation cystitis, radiation gastritis, bleeding into secondary deposits
and oedema in cerebral secondary deposits (extremely rare)
• Possible late effects
– Dry mouth and abnormal taste
– Sialadenitis and lachrymal gland dysfunction
– Secondary malignancy (very small)  leukaemia (RR 2, solid tumor
– Radiation fibrosis
– risk of miscarriage
– Men Infertility
 Pre-ablation Whole Body Scans
• Controversial
• Justification :
1. to determine how much residual thyroid tissue has been
left after thyroidectomy,
2. to define the presence of functioning metastases, thus
accurately staging the disease,
3. to determine whether pre-ablation preparation is
adequate for treatment with 131I or not,
4. to determine whether patient is surgically ablated or not,
5. to ensure the proposed high dose of therapeutic 131I not
irradiating a physiological site such as the breasts.
RADIOTHERAPY FOR
THYROID CANCER
Differentiated Thyroid Cancer
• Differentiated thyroid cancer
– arising from thyroid follicular epithelial cells,
– majority of thyroid cancer
• Type:
– papillary cancer (85%)
– Follicular (12%)
– Poorly differentiated (<3%)
• Role of Radiotherapy :
– The benefit of EBRT in addition to surgery, RAI ablation dan TSH  has
been such a subject of debate
 Indications for EBRT in differentiated thyroid cancer
(British Thyroid Association and Royal College of Physicians published guidelines)
• Adjuvant external beam radiotherapy
– The main indications:
• Gross evidence of local tumour invasion at surgery, presumed to have
significant macro or microscopic residual disease, particularly if the residual
tumour fails to concentrate sufficient amounts of radioiodine
• Extensive pT4 disease in patients over 60 years of age with extensive
extranodal spread after optimal surgery, even in the absence of evident
residual
• High-dose external beam radiotherapy as part of primary treatment
– Indicated for :
• unresectable tumours that do not concentrate radioactive iodine
• unresectable bulky tumours in addition to radioactive iodine treatment.
• Paliative
– Bone metastases (Pain, Epidural spinal cord compression)
– Brain metastases
– Bleeding
Local Regional Control Rate in High-Risk Differentiated Thyroid Cancer in Patients with
No Gross Residual Disease After Surgery: 10-Year Local Recurrence-Free Rates
Patients given external RT  higher cause specific survival (p= 0.038) and
local relapse free rate (p=0.01) compared with those who did not receive it
(papillary tumors and postoperative microscopic residual disease)
Cause specific survival and local-regional relapse-free rates for patients over the age of 60
years who have completely resected differentiated thyroid cancer and evidence of Extra
Thyroidal Extension, with or without XRT.
aged 40 years or
older with
differentiated
thyroid cancer
lymph node positive
patients aged 40 years
or older with invasive
PTC with
1. Thyroid 2016; 26(1): 1-133.
 Consensual
indications of
radiotherapy
among all
International
Recommendations
Medullary Thyroid Cancer

• Originates : thyroid parafollicular cells

• 3-4% of the malignant neoplasms that affect this gland.
• 25% of these cases are hereditary due to activating mutations in
the REarranged during Transfection (RET) proto-oncogene.
– (multiple endocrine neoplasia 2A (MEN2A), MEN2B and familial
medullary thyroid cancer (FMTC)
• The role of radiotherapy  less clear
– has not been shown to improve survival, but may improve the relapse-
free rate if there is gross microscopic residual disease or extensive
nodal disease.
– Radiotherapy may control local symptoms in cases of inoperable or
secondary disease.
The management of medullary thyroid cancer
The aim of EBRT : to improve locoregional control in patients at high
risk of cervical relapse  extrathyroid extension and significant nodal
burden.
Anaplastic Thyroid Cancer
• poor prognosis.
• rapidly growing and infiltrative nature
– Locally aggressive disease : involving the regional lymph nodes,
perithyroidal fat, neck musculature, larynx, trachea, esophagus,
and vasculature of the neck and mediastinum.
• Aggressive local therapy is often recommended, although
there is no randomized evidence to support this approach.
• Distant metastases : <50% of newly diagnosed cases (lung)
• Addition to locoregional treatment, end-of-life issues and
palliative care should be addressed early in the disease
process
• One common approach in the management of ATC, either as primary
treatment or after surgery, uses RT with concurrent weekly low-dose
doxorubicin (10 mg/m2 ).
Anaplastic Thyroid Cancer
 Radiotherapy
• The target volume : thyroid bed and draining
lymph nodes (perithyroid lymph nodes in the
central compartment, paratracheal, pretracheal,
superior mediastinum and cervical lymph nodes)
• The aim is to deliver 60 Gy in 30 fractions over 6
weeks.
– Technique : 2D >> 3D >> IMRT
• Organs at risk from radiation damage : the spinal
cord, oesophagus, oral cavity, larynx and trachea
2D technique

• anterior and posterior parallel opposed fields encompassing

the thyroid bed, bilateral cervical lymph node chains (levels
Ib–VI) and the superior mediastinum (level VII).
• Toxicity >>
3D technique
• three-dimensional
conformal radiotherapy
• boost to the phase 2
volume for radical
external beam
radiotherapy to the
thyroid gland.
IMRT in Thyroid Cancer
• Dose distribution of external beam
radiotherapy to the thyroid gland
using intensity-modulated
radiotherapy,

• Facilitates shaping of the isodoses

around the concave planning
target volume

• minimising the dose to the spinal

cord
 IMRT in Thyroid Cancer
• MD Anderson Cancer Center :
with stage 3–4 differentiated
thyroid carcinomas.
• Schwartz’s retrospective studies :
• Less frequent severe late morbidity
(12% vs. 2%).
• did not impact on survival
• MSKCC study: No significant
differences in toxicity were
identified between patients
who received conventional RT
and those who underwent
IMRT
 Target volume definition
• Gross Tumour Volume (GTV)
– Any macroscopic residual disease
– Any sites where tumour was excised with a known
positive margin
• Clinical Target Volume (CTV)
– depend on the sites of residual disease, excision
margins and the extent and risk of lymph node
involvement.
• Planning Target Volume (PTV)
– The CTV is expanded by 3–5 mm
 Take Home Message
• US is essential to evaluate thyroid nodule
• RAI adjuvant therapy is recommended in
high risk
• Radiation therapy has a role in selected
patients who are at high-risk for local
recurrence with differentiated carcinomas,
medullary carcinomas and poorly
differentiated carcinoma.
Thank You