재발한 분화갑상선암의 치료
Management of Recurrent Differentiated Thyroid Carcinoma
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Patients with well differentiated thyroid carcinoma (WDTC) generally have good prognosis with appropriate therapy, but those with recurrences have higher disease specific mortality and poor quality of life requiring clinical attention. Recurrences occur in 5-20% as loco-regional form and as distant metastasis in 10-20% in long-term follow-up after initial therapy. Soft tissue recurrences as a form of local recurrence require aggressive therapy including wide excision and postoperative adjuvant therapy as they have dismal prognosis. There are controversies in proper management of loco-regional recurrences in neck lymph node, because improvement in clinical outcome of those patients through randomized, prospective study had never been documented and because it is not clear if lymph node recurrences could be a focus of further metastasis of cancer cells. Management includes surgery (compartment-oriented lymph node dissection), alcohol injection or radiofrequency ablation and simple observation. Adjuvant radioiodine therapy is not useful after re-operation, especially high dose radioiodine had been done as initial therapy. Recurrences as distant metastasis require thorough evaluation and proper management according to site and progression of each lesion. Palliative surgery if critical structure is endangered, radioiodine therapy in “radioactive iodine (RAI)-avid” lesions, external beam radiation therapy or IV bisphosphonate, embolization should be considered in bone metastasis according to clinical setting. RAI-avid lung metastasis can be managed with radioiodine, but there is no available therapeutic modality in ”non-RAI-avid” lung metastatic lesions. Clinical trials using new targeted agents can be considered in those patients. There had been many trials to enhance/restore iodine uptake in metastatic lesions, but there is no clinically available agent yet. Further studies are required for development of agents to restore/enhance iodine uptake to improve efficacy of RAI therapy.
Abstract
Patients with well differentiated thyroid carcinoma (WDTC) generally have good prognosis with appropriate therapy, but those with recurrences have higher disease specific mortality and poor quality of life requiring clinical attention. Recurrences occur in 5-20% as loco-regional form and as distant metastasis in 10-20% in long-term follow-up after initial therapy. Soft tissue recurrences as a form of local recurrence require aggressive therapy including wide excision and postoperative adjuvant therapy as they have dismal prognosis. There are controversies in proper management of loco-regional recurrences in neck lymph node, because improvement in clinical outcome of those patients through randomized, prospective study had never been documented and because it is not clear if lymph node recurrences could be a focus of further metastasis of cancer cells. Management includes surgery (compartment-oriented lymph node dissection), alcohol injection or radiofrequency ablation and simple observation. Adjuvant radioiodine therapy is not useful after re-operation, especially high dose radioiodine had been done as initial therapy. Recurrences as distant metastasis require thorough evaluation and proper management according to site and progression of each lesion. Palliative surgery if critical structure is endangered, radioiodine therapy in “radioactive iodine (RAI)-avid” lesions, external beam radiation therapy or IV bisphosphonate, embolization should be considered in bone metastasis according to clinical setting. RAI-avid lung metastasis can be managed with radioiodine, but there is no available therapeutic modality in ”non-RAI-avid” lung metastatic lesions. Clinical trials using new targeted agents can be considered in those patients. There had been many trials to enhance/restore iodine uptake in metastatic lesions, but there is no clinically available agent yet. Further studies are required for development of agents to restore/enhance iodine uptake to improve efficacy of RAI therapy.
참고문헌 (29)
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