MS8106, P.O. Box 6511, Aurora, Colorado 80045, USA.
J Clin Endocrinol Metab. 2010 Mar;95(3):987-93. doi: 10.1210/jc.2009-2305.
Patients with distant, or extracervical, metastases from differentiated thyroid cancer require multimodality diagnostic, therapeutic, and monitoring approaches. Whereas cure is the initial goal, especially in those with small, radioiodine-avid pulmonary metastases, improved survival and management of symptoms become the primary objective in many patients with persistent disease, especially those with bone metastases. Levothyroxine therapy with suppression of serum TSH is a primary therapy in all patients with advanced differentiated thyroid cancer, and this therapy has been shown to improve overall survival and slow disease progression. Radioiodine is also an important systemic therapy for those patients with radioiodine-avid disease who respond to this targeted therapy. In this review, we compare standard fixed-dose radioiodine therapy vs. the dosimetric approach. Directed therapy such as external beam radiotherapy, surgery, and embolization is generally considered for large or painful lesions. Careful collaborations with multiple specialties through tumor boards or other mechanisms help to optimize complex management decisions in these patients with advanced thyroid cancer. Multimodality monitoring focused on the organ of interest such as pulmonary [computed tomography (CT)], bone (magnetic resonance imaging, CT, bone scan), and brain (CT, magnetic resonance imaging) metastases as well as general metastatic surveillance (bone scan, (18)F-fluorodeoxyglucose-positron emission tomography) aid decision making about careful monitoring vs. directed or systemic therapy. (18)F-fluorodeoxyglucose-positron emission tomography imaging has an additional role in patient prognosis and guiding directed therapy for fluorodeoxyglucose-avid lesions. Patients with asymptomatic, stable, radioiodine-resistant metastases may be carefully monitored for disease progression. Patients with symptomatic disease should receive directed therapy with the goal of symptom relief. Patients with progressive metastatic disease should be considered for clinical trials or targeted systemic therapy (sorafenib or sunitinib), although these agents are not Food and Drug Administration (FDA) approved for patients with thyroid cancer. The goals of therapy for patients with extracervical metastases should be to improve survival, relieve symptoms, and decrease the morbidity of disease progression and limit the morbidity associated with therapy.
患有分化型甲状腺癌远处或宫颈外转移的患者需要采用多模式的诊断、治疗和监测方法。虽然治愈是最初的目标，特别是在那些具有小的、碘放射性肺转移灶的患者中，但在许多持续性疾病患者中，尤其是那些有骨转移的患者中，改善生存和管理症状成为主要目标。所有晚期分化型甲状腺癌患者均采用左旋甲状腺素抑制血清 TSH 的治疗，这种治疗已被证明可以提高总体生存率并减缓疾病进展。对于那些对这种靶向治疗有反应的碘放射性疾病患者，碘也是一种重要的全身治疗方法。在本综述中，我们比较了标准固定剂量碘治疗与剂量学方法。对于大的或疼痛的病变，通常考虑进行外部束放疗、手术和栓塞等靶向治疗。通过肿瘤委员会或其他机制与多个专业科室的仔细合作有助于优化这些晚期甲状腺癌患者的复杂管理决策。针对特定器官的多模式监测，如肺部[计算机断层扫描（CT）]、骨骼（磁共振成像、CT、骨扫描）和脑（CT、磁共振成像）转移，以及一般转移性监测（骨扫描、（18）F-氟脱氧葡萄糖正电子发射断层扫描），有助于决定对疾病进行仔细监测、靶向或全身治疗。（18）F-氟脱氧葡萄糖正电子发射断层扫描成像在患者预后和指导氟脱氧葡萄糖放射性病变的靶向治疗方面具有额外作用。对于无症状、稳定、碘难治性转移的患者，可仔细监测疾病进展情况。对于有症状的患者，应采用靶向治疗以缓解症状。对于进行性转移性疾病患者，应考虑临床试验或靶向全身治疗（索拉非尼或舒尼替尼），尽管这些药物尚未获得美国食品和药物管理局（FDA）批准用于甲状腺癌患者。对于宫颈外转移患者，治疗的目标应该是提高生存率、缓解症状、降低疾病进展的发病率和与治疗相关的发病率。
