ROLE OF EXTERNAL BEAM RADIATION IN THYROID MALIGNANCIES

Faisal Vali, MSc, MD, Radiation Oncology

Epidemiology

Lifetime risk of thyroid malignancy < 1% ~56,000 new cases, ~1,800 deaths (~3.2%) Btw 15-24 years, it is 7.5 to 10% of all cancers Peak incidence is at 49 years

NCCN v2.2012

Thyroid Malignancies
Well Differentiated Thyroid Cancer (WDTC): 94%
Papillary

80%

Follicular

11%

Hundahl SA, Fleming ID, Fremgen AM, Menck HR. A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see comments]. Cancer 1998;83:2638-2648. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9874472.

Hurthle

3%

Thyroid Malignancies

Medullary Thyroid Cancer : 4%

Anaplastic Thyroid Cancer : 2%

Thyroid Lymphoma (<1%)

Hundahl SA, Fleming ID, Fremgen AM, Menck HR. A National Cancer Data Base report on 53,856 cases of thyroid carcinoma treated in the U.S., 1985-1995 [see comments]. Cancer 1998;83:2638-2648. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9874472.

Survival Data

10 y OS Differentiated Thyroid Cancer

Papillary:

93% Follicular: 85% Hurthle: 76%

Anaplastic : MS of 3-7 mo, 5y 8% Medullary: 10 y OS @ 75% Thyroid Lymphoma: 5y OS: 64%

Staging

Staging

Size based
T1

2cm T2 4cm T3 > 4cm intrathyroid

OR

any size w minimal ETE: perithyroid soft tissues

T4

a = ETE: larynx, esophagus, or Recurrent Laryngeal T4 b = ETE: prevertebral fascia, encases carotid

Staging

External Beam RT

I-131is radioactive DECAY

I-131: Radioactive Decay of an unstable nucleus release electrons and photons

X-Ray Irradiation
70%

30% EBRT: Generation of X-rays by

slowing down accelerated electrons, which then release electrons in matter

Rationale for EBRT

External beam radiotherapy carries the potential for improving locoregional disease control

Locoregional : primary site and regional nodes (which is where the radiation is aimed)

Rationale for EBRT

EBRT in Well Differentiated TCa

Management of Differentiated Thyroid Cancer

No data from prospective randomized trials for any modality Most data is from large non-randomized patient cohorts (prospective or retrospective) Treatment of choice is Surgery Adjuvant Tx: radioiodine and thyroxine

Papillary/Follicular/Hurthle

Data for EBRT (MDACC)

Retrospective: 1996 2005 of 131 pts High Risk: Hurthle cell, tall cell, clear cell, or poor Median F/U: 38 months (3.5 years) 4y LRFS = 79%, DSS = 76%, OS = 73% 2% clinically significant toxicity with

Adjuvant EBRT Consideration

Always consider EBRT, if poor I-131 uptake If 50y AND T4 dz with R1/R2 resections ( microscopic residual dz) If < 50 y AND T4b or, Extensive T4a + poor histology (hurthle, tall, etc.) If Lymph Node positive & Extensive Extracapsular extension or V. High Nodal Ratio (>80-90%) Any recurrence (in thyroid bed or neck): EBRT should be considered following surgery and radioiodine

Radiation Details (WDT)

Target: Thyroid bed & Level 2-6 nodes (consider 7) Radiation Dose: 66 Gy in 33 fractions to Higher Risk Areas 56 Gy in 33 fractions to lower risk CTV.

K&A 2011

EBRT in Anaplastic TCa

Anaplastic

One of the most lethal of all cancers : 15-50% present with mets (Lungs 90%, 15% bone, 5% CNS) Surgical Resection is rarely possible Concentrate RAI very infrequently EBRT Rationale is to maximize local control and prevent death from

Anaplastic

Radiation Details

Target: thyroid bed and the adjacent lymph nodes (avoid entire neck or mediastinum) If KPS 60 & M0 60 Gy in 40 fractions, BID Taxane If KPS < 60 palliative 20 Gy in 5 fractions, may repeat in 4 weeks if there is mild response

EBRT in Medullary Cancer

EBRT in Medullary Thyroid Cancer

No role for I-131

If resection is incomplete, calcitonin remains elevated, T4 dz or recurrence consider EBRT

Medullary Thyroid Cancer RT Details

TARGET: thyroid bed, residual dz, cervical nodes

56 Gy in 33 fractions to the cervical lymph nodes

66 Gy in 33 fractions to potential residual disease

EBRT in Thyroid Lymphoma

Thyroid Lymphoma

Diffuse Large B Cell (aggressive) 70% > MALT(indolent) vs 30% Staged according to Lymphoma DLBCL: Chemo (R-CHOP) + EBRT MALT: RT alone Hashimotos: risk is 60 times higher

Thyroid Lymphoma

35 Gy in 20 fractions to encompass the thyroid, neck nodes bilaterally, and superior mediastinal nodes If not indolent, DLBCL R-CHOP x 3 cycles + RT 4 weeks later

Metastastases

Bone Metastases (Uptodate)

Bone mets (3% remission post RAI) dont respond as well to radioiodine as Lung mets do

All patients with symptomatic bone mets should be referred for EBRT (40-50Gy)

Toxicities from EBRT

Potential Acute Toxicities

Moderate skin erythema Dry desquamation and, rarely, moist desquamation Mucositis of the esophagus, trachea, and larynx, subsides within 2-4 weeks (may require a soft diet and analgesics)

Long Term Toxicity

Well-planned radiotherapy treatment regimens rarely have serious long-term complications. Most Common: skin telangiectasias and skin pigmentation. Esophageal stenosis is rare and Tracheal stenosis is extremely rare.

Conclusions

Treatment Paradigms

WDTCa = Surgery Radioactive Iodine EBRT TSH suppression Anaplastic = Local Control is important to QOL
hyperfractionated

EBRT + taxane based

chemo

Medullary = Surgery (no RAI, no TSH suppression) EBRT

Conclusions

No prospective randomized trials for thyroid cancer

Role for EBRT is still being defined

There is retrospective data that suggests it can be done safely and effectively, especially with IMRT

Refer to RadOnc if any

Unresectable tumors/Gross Positive margins High risk histologies: tall cell, columnar, hurthle Poor RadioIodine uptake by tumor Extrathyroidal extension at time of surgery Large Nodal Ratio and/or Extensive ECE Palliation for symptomatic recurrent tumor or mets

Thank you!

Questions??