iodine in metastatic carcinoma of thyroid & management of thyrotoxicosis

8/17/2019 Iodine in Metastatic Carcinoma of Thyroid & Management Of Thyrotoxicosis

1/17

Iodine in MetasCarcinoma of Thyro

ManagemeThyrotoxi

Shubh

Rol


2/17

Iodine in Metastatic CarcinomPatients with dierentiated (papillary or follicular) thyroid cancer that has sp

(metastasized) eyond the thyroid may e treated with radioacti!e iodine fo#adioacti!e iodine (#$I) therapy% which contains a larger dose of radiation than thdiagnostic radioactive iodine is absorbed b! both normal th!roid and di"erentiated th!

destro!ing an! th!roid tissue and cancer cells that ma! remain after surger!# $!%icall!

doses of radioactive iodine & given as either a li'uid or a %ill ( are needed to com%lete

tissue# This therapy has een shown to increase sur!i!al in some patients witpapillary or follicular thyroid cancer " #$I therapy is not eecti!e for patientsthyroid carcinoma or anaplastic thyroid carcinoma% which do not asor iodin

$h!roid stimulating hormone )$S*+ %roduced b! the %ituitar! gland hel%s th!roid tissu*owever thyroid hormone therapy can reduce T' le!els and decrease the e#$I therapy" In the past% patients were reuired to stop taing thyroid replaca period of time prior to eginning #$I therapy to increase T' production" *thyroid hormone therapy can temporarily result in hypothyroidism )low th!rowhich causes a variet! of s!m%toms such as fatigue% depression% weight gain% conmuscle aches% and reduced concentration"


3/17

M,N,-.M.N$ / $*R/$/2IC/SIS

Management of $h!roto3icosis 4 *!%erth!roidism focus%harmacothera%! consultations 5 long(term monitoriconducted b! an endocrinologist which includes :

,nti $h!roid 6rugs

S!m%tomatic Relief

Radioactive Iodine $hera%!6iet 5 .3ercise

Management of /%thalmo%ath! 4 6ermo%ath!

$h!roidectom!


4/17

,N$I($*R/I6 6R7-S,ntith!roid drugs )eg methima8ole and %ro%!lthiouracil+ have been use

h!%erth!roidism since their introduction in the 190s# $hese medicationem%lo!ed for long(term control of h!%erth!roidism in children adolesce%regnant women# In adult men and non%regnant women the! are used

h!%erth!roidism before denitive thera%! with radioactive iodine# $he! formation and cou%ling of iodot!rosines in th!roglobulin# $his inhibition

gradual reduction in th!roid hormone levels over ;(< wee=s or longer# ,

%ro%!lthiouracil is inhibition of conversion of th!ro3ine )$+ to triiodoth!

$> is more biologicall! active than $@ thus a 'uic= reduction in $> levelswith a clinicall! signicant im%rovement in th!roto3ic s!m%toms#

$he antith!roid drug dose should be titrated ever! wee=s until th!roid

normali8e# Some %atients with -raves disease go into a remission after 1;(1< months and the drug can be discontinued# Notabl! half of the %ainto remission e3%erience a recurrence of h!%erth!roidism within the fo

Nodular forms of h!%erth!roidism )ieto3ic multinodular goitre and to3ic

%ermanent conditions and will not go into remission#


5/17

$he dose range :Propylthiouracil : A0(1A0 mg $I6 followed b! ;A(A0

B64$I6 as maintenance dose

Methimazole : A(10 mg $I6 initiall! A(1A mg dail! maintenance dose#


6/17

SMP$/M,$IC R.I.Man! of the neurologic and cardiovascular s!m%toms of

th!roto3icosis are relieved b! eta+locer therapy# Befthera%! is initiated the %atient should be e3amined for sigs!m%toms of deh!dration that often occur with h!%erth!ro,fter oral reh!dration beta(bloc=er thera%! can be startedbloc=er thera%! should not be administered to %atients wit

signicant histor! of asthma#Calcium channel locers )eg vera%amil and diltia8em

used for the same %ur%oses when beta(bloc=ers are contraor %oorl! tolerated# $hese thera%ies should be ta%ered andonce th!roid functions are within the normal range#


7/17

R,6I/,C$ID. I/6IN. $*.R#adioacti!e iodine is administered orall! as a single dose in ca%sule or li'uid form# $h

'uic=l! absorbed and ta=en u% b! the th!roid# No other tissue or organ in the bod! is caretaining the radioactive iodine@ conse'uentl! ver! few adverse e"ects are associated

The treatment results in a thyroid+speci,c in-ammatory response% causing ,destruction of the thyroid o!er wees to many months" -enerall! the dose of 1>1

EA(;00 FCi4g of estimated th!roid tissue divided b! the %ercent of 1;> I u%ta=e in ; houintended to render the %atient h!%oth!roid# ,dministration of lithium in the wee=s folloiodine thera%! ma! e3tend the retention of radioactive iodine and increase its eGcac!#

#adioacti!e iodine should ne!er e administered to pregnant women% ecausthe placenta and alate the foetus.s thyroid% resulting in hypothyroidism" imreastfeeding is a contraindication% in that the radioisotope is secreted in re

Homen will continue to receive increased radiation to the breast from radioactive iodinmonths after ceasing lactation@ accordingl! initiation of this thera%! should be dela!edpractice to chec for pregnancy efore starting radioacti!e iodine therapy anrecommend that the patient not ecome pregnant for at least /+0 months afttreatment or until thyroid functions normalize" No e3cess foetal malformations omiscarriage rates have been found in women %reviousl! treated with radioactive iodineh!%erth!roidism#


8/17


9/17

6I.$ ,N6 .2.RCIS.

If !ou are currentl! in the throes of h!%erth!roidism and are th!roto3ic itnote that !our th!roid hel%s to control gastric em%t!ing secretion of digeand motilit! of the digestive tract# Hhen !oure th!roto3ic des%ite a voraa%%etite !ou might lose weight and have fre'uent bowel movements#

Increase !our calcium inta=e b! eating more butter cream cheese and o%roducts# $his will also hel% to =ee% !our weight u%# Peanut butter ma!onanimal fats can hel% as well# $o reduce diarrohea cut down on fruit Juicesfruits# Peanut butter is also good for binding# Sometimes th!roto3ic %eo%sudden lactose intolerance which can lead to gas and other un%leasantri

the case eliminate all mil= %roducts and ta=e a calcium su%%lement whilefat from the other foods mentioned above#

Sta! awa! from ca"eine alcohol and cigarettes@ all ma! stimulate !our hwant to ta=e vitamin su%%lements as well# )Ditamins , 6 and . are storeand can be lost through e3cretion if !ou are th!roto3ic or h!%erth!roid#+ Hin balance again !ou will need to cut down on !our fat and calcium inta=


10/17

M,N,-.M.N$ / /P$*,M/P,lthough A0K of %atients with -raves disease have mild signs and s!m

th!roid e!e disease onl! AK develo% severe o%hthalmo%ath! )eg di%loeld decits or blurred vision+# ess serious o%hthalmologic s!m%toms

%hoto%hobia irritation and tearing+ are treated with tight(tting sunglashould be worn at all times when the %atient is outside and with salinethat are ta=en as necessar! for comfort#

If e3%osure =eratitis is sus%ected the %atient should be monitored b! ao%hthalmologist# $his condition usuall! occurs when e!elid closure is inthe cornea is e3%osed at night when the %atient does not blin=# $!%icalcom%lain of irritation and tearing on awa=ening# $reatment includes ad

saline gel or dro%s and ta%ing e!elids closed with %a%er ta%e before sleo%hthalmologists are concerned about corneal abrasion from the ta%e arecommend that %atients wear goggles at night to =ee% the e!es moist

, medical emergenc! occurs when suGcient orbital edema e3ists to canerve com%ression with earl! loss of color vision and orbital %ain# Hithocontinued %ressure on the o%tical nerve ma! cause %ermanent vision loglucocorticoids are administered with consideration for orbital decom%

surger! and ocular radiation thera%!#


11/17

M,N,-.M.N$ / 6.RM/P,$Inltrative dermo%ath! usuall! develo%ing over the

e3tremities is characteri8ed b! an accumulation ofgl!cosaminogl!cans and inLammator! cells in the des=in changes t!%icall! include a non%itting er!themaedema of the anterior shins# 6ermo%ath! can occur a

sites of re%eat trauma# $he dermo%ath! usuall! occuthe %resence of signicant o%hthalmo%ath!#

No e"ective treatment e3ists# Nightl! occlusive wra%a"ected site are recommended with %lastic wra% usethe a%%lication of a high(%otenc! to%ical steroid crea


12/17

$*R/I6.C$/M

Subtotal th!roidectom! is the oldest form of treatment for h!%ert

$otal th!roidectom! and combinations of hemith!roidectomies an

contralateral subtotal th!roidectomies also have been used#

Because of the e3cellent eGcac! of antith!roid medications and riodine thera%! in regulating th!roid function th!roidectom! is ge

reserved for s%ecial circumstances including the following:

Severe h!%erth!roidism in children

Pregnant women who are noncom%liant with or intolerant of antit%harmacothera%!

Patients with ver! large goiters or severe o%hthalmo%ath!

Patients who refuse radioactive iodine thera%!

Patients with refractor! amiodarone(induced h!%erth!roidism


13/17

/N-($.RM M/NI$/RIN- Care after initiation of antithyroid medication

,fter ( wee=s antith!roid medications usuall! must be reduced@ otherwise tbecomes h!%oth!roid# 'ypothyroidism causes the usual symptoms of fatweight gain% and in patients with 1ra!es disease% it has een anecdotawith worsening of thyroid ophthalmopathy" Initiall! the %atient should hafunction tests %erformed ever! ( wee=s until th!roid hormone levels are stabdosage of antith!roid medication#

Patients with non+1ra!es hyperthyroidism rarely experience remission

who are %laced on long(term antith!roid drug thera%! with the goal of remissiotests of th!roid function should be %erformed at least ever! > months for the

In %atients with -raves disease antith!roid medication should be sto%%ed or d1;(1< months to determine whether the %atient has gone into remission# In theremission is de,ned as a normal T' le!el after cessation of antithyrotherapy"

/nce a %atient with -raves h!%erth!roidism becomes euth!roid on oral antith!

medication other denitive treatment such as radioactive iodine thera%! or sube considered# ,lthough a signicant fraction of %atients with -raves disease g


14/17

Care after radioacti!e iodine alation

,blation of the gland occurs over ;(A months after radioactive iodine th%atients become h!%oth!roid# Chec=ing th!roid functions ever! ( we

%atient stabili8es is recommended#

/nce the th!roid hormone levels start falling into the low(normal range

reasonable to sto% antith!roid medications and to consider starting lowhormone re%lacement before the %atient becomes h!%oth!roid@ howev

physicians prefer to document persistently ele!ated T' !aluepatient o antithyroid medication efore starting thyroid hormreplacement"

tarting with partial or low+dose thyroid hormone replacementrecommended (53+65 7g8day% ad9usted e!ery 0+: wees to normT' le!el)" Several wee=s after1>1 I thera%! %atients can in rare caseth!roto3ic as a result of vigorous th!roid destruction and release of %re

hormone# $his %rocess often is accom%anied b! a %ainful radiation(indth!roiditis that can be treated with nonsteroidal anti(inLammator! drug

glucocorticoids#

In addition radioablation can cause the release of th!roid antigens and

the autoimmune th!roid disease %rocess# In such cases -raves diseas


15/17

Care after thyroid surgery

Patients whose th!roid functions normali8e after surger! re'uire rfollow(u% because hypothyroidism (from the chronic thyroid

recurrent hyperthyroidism% or thyroid eye disease may desome time in the future" Most %atients remain euth!roid after or lobectom! %lus isthmusectom! to treat a to3ic adenoma or to3multinodular goiter with a dominant nodule# $o ensure normal th!

th!roid function tests should be obtained >( wee=s after a lobec

,fter subtotal th!roidectom! for h!%erth!roidism and cessation o

thera%! most %atients become h!%oth!roid de%ending on how mfunctional tissue is left b! the surgeon# Partial re%lacement )$ A0

is recommended in these %atients beginning shortl! after the %ro

$h!roid function tests should be monitored (< wee=s %osto%erat $ dosage should be adJusted to maintain a normal $S* level#


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iodine in metastatic carcinoma of thyroid & management of thyrotoxicosis

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