This document provides an introduction to thyroid cancer and radioiodine refractory disease. It discusses the epidemiology of thyroid cancer, noting it is the most common endocrine tumor. Histological classification of thyroid cancer according to the WHO 2017 guidelines is presented. Management concepts are reviewed including staging, surgery, radioiodine therapy, and systemic treatment. Refractory disease is defined as disease that continues to progress despite radioactive iodine treatment. Prognostic factors and outcomes for patients with radioiodine refractory disease are discussed.

2. Introducción al cáncer de tiroides y refractariedad al yodo
radiactivo
Maribel del Olmo García
Endocrinología y Nutrición
Hospital La Fe (Valencia)

3. INTRODUCCIÓN

5. ¿Doctor qué es lo que
tengo?
No se preocupe, sólo
es un cáncer de
tiroides…..

6. EPIDEMIOLOGÍA

7. ¿Es frecuente tener un cáncer de
tiroides?
El 50% de la población tiene nódulos tiroideos
El 5-10% serán un ca de tiroides
Williams textbook of Endocrinology, 14th edition.
EL CÁNCER DE TIROIDES ES EL TUMOR ENDOCRINO MÁS
FRECUENTE

8. WHO 2018

9. WHO 2018
Es más prevalente en
mujeres convirtiéndose
el 4º en frecuencia

10. ¿Cuál es la probabilidad de
morir por un ca de tiroides?
1/200,000 pacientes
Williams textbook of Endocrinology, 14th edition.

11. American Cancer Society 2019

12. FISIOPATOLOGÍA

13. Veschi V, Verona F, Lo Iacono M, D'Accardo C, Porcelli G, Turdo A, Gaggianesi M, Forte S, Giuffrida D, Memeo L, Todaro M. Cancer
Stem Cells in Thyroid Tumors: From the Origin to Metastasis. Front Endocrinol (Lausanne). 2020 Aug 25;11:566.

14. Williams textbook of Endocrinology, 14th edition.
Modelo de carcinoma de
tiroides en cuanto a iniciación y
progresión de alteraciones
genéticas primarias

15. CA MEDULAR
DE TIROIDES
FAMILIAR 20-30%
ESPORÁDICO

16. CLASIFICACION HISTOLÓGICA

17. CLASIFICACION
HISTOLÓGICA DE LA
OMS 2017
Lloyd RV. WHO classification of tumors of endocrine origin. 2017

18. Lloyd RV. WHO classification of tumors of endocrine origin. 2017

19. Lloyd RV. WHO classification of tumors of endocrine origin. 2017

20. Lloyd RV. WHO classification of tumors of endocrine origin. 2017

21. Lloyd RV. WHO classification of tumors of endocrine origin. 2017

22. Lloyd RV. WHO classification of tumors of endocrine origin. 2017

23. MANEJO: CONCEPTOS GENERALES

25. ESTADIAJE
TNM
8º CLASIFICACION TNM AJCC

26. ESTADIAJE
TNM
8º CLASIFICACION TNM AJCC
N0 a. Confirmado histológicamnente
b. Radiológicamente
N1 a. Compartimento central VI y VII
b. Compartimentos laterales I-V
M0 No metástasis
M1 Metástasis

27. ESTADIAJE
TNM
8º CLASIFICACION TNM AJCC

28. CIRUGÍA
Lobectomía
Tiroidectomía
+/- LINFADENECTOMÍIA TERAPÉUTICA O
PROFILÁCTICA
ATA GUIDELNES 2015

29. ATA GUIDELNES 2015

30. ATA GUIDELNES 2015

31. ATA GUIDELNES 2015

32. CARCINOMA DE TIROIDES METASTÁSICO:
CONCEPTOS GENERALES

33. ERUDIT
STUDY
V CURSO DE ACTUALIZACIÓN EN ENDOCRINOLOGIA Y NUTRICION. 2020. Dr.Aller
68%
32%
99%
1%
NO RAI-R
RAI-R
18 18 18 14 7 7 3
53 52 47 34 15 5 4
117 110 93 45 16 3 3
0 1 3 6 9 12 15
Time to event (years)
0.0
0.2
0.4
0.6
0.8
1.0
Survival
Probability
1
2
3
3: From the first RAI therapy with structural incomplete response to death
2: From the first RAI therapy with biochemical incomplete response to death
1: From the first RAI therapy with excellent response to death
Product-Limit Survival Estimates
With Number of Subjects at Risk and 95% Hall-Wellner Bands
18 18 18 14 7 7 3
53 52 47 34 15 5 4
117 110 93 45 16 3 3
0 1 3 6 9 12 15
Time to event (years)
0.0
0.2
0.4
0.6
0.8
1.0
Survival
Probability
1
2
3
3: From the first RAI therapy with structural incomplete response to death
2: From the first RAI therapy with biochemical incomplete response to death
1: From the first RAI therapy with excellent response to death
Logrank p=0.0212
+ Censored
Product-Limit Survival Estimates
With Number of Subjects at Risk and 95% Hall-Wellner Bands
18 18 18 14 7
53 52 47 34 15
117 110 93 45 16
0 1 3 6 9
Time to event (years)
0.0
0.2
0.4
0.6
0.8
1.0
Survival
Probability
1
2
3
3: From the first RAI therapy with structural incom
2: From the first RAI therapy with biochemical inco
1: From the first RAI therapy with excellent respons
Product-Limit Survival Estimat
With Number of Subjects at Risk and 95% Hall-W
18 18 18 14 7
53 52 47 34 15
117 110 93 45 16
0 1 3 6 9
Time to event (years)
0.0
0.2
0.4
0.6
0.8
1.0
Survival
Probability
1
2
3
3: From the first RAI therapy with structural incom
2: From the first RAI therapy with biochemical inco
1: From the first RAI therapy with excellent respons
Logrank p=0.0212
+ Censored
Product-Limit Survival Estimat
With Number of Subjects at Risk and 95% Hall-W

34. ORDEN DE JERARQUICO EN EL
TRATAMIENTO
Cirugía de enf locorregional
Tratamiento con I131
RT o tratamientos locorregionales
Tratamiento sistémico
ATA GUIDELNES 2015

35. TRATAMIENTO
CON I 131
Treatment of pulmonary metastases
Pulmonary micrometastases should be treated with RAI therapy and RAI
therapy should be repeated every 6–12 months as long as disease continues to
concentrate RAI and respond clinically because the highest rates of complete
remission are reported in these subgroups.
100-200 mCi
ATA GUIDELNES 2015

36. TRATAMIENTO
CON I 131
Treatment of pulmonary metastases
Radioiodine-avid macronodular metastases may be treated with RAI and
treatment may be repeated when objective benefit is demonstrated (decrease in the
size of the lesions, decreasing Tg), but complete remission is not common and
survival remains poor
100-200 mCi
ATA GUIDELNES 2015

37. TRATAMIENTO
CON I 131
Treatment of bone metastases
RAI therapy of iodine-avid bone metastases has been associated with
improved survival and should be employed, although RAI is rarely
curative.
100-200 mCi
ATA GUIDELNES 2015

38. TRATAMIENTO
CON I 131
Treatment of bone metastases
RAI therapy of iodine-avid bone metastases has been associated with
improved survival and should be employed, although RAI is rarely
curative.
100-200 mCi
ATA GUIDELNES 2015

39. TRATAMIENTO
CON I 131
Treatment of empiric RAI therapy be considered for Tg-positive, RAI diagnostic scan–
negative patients
Empiric (100–200 mCi) or dosimetrically determined RAI therapy may be considered in
patients with more significantly elevated serum Tg levels, rapidly rising serum Tg levels,
or rising ant-Tg antibody levels, in whom imaging (anatomic neck/chest imaging and/or
18FDG-PET/CT) has failed to reveal a tumor source that is amenable to directed therapy. The
risk of high cumulative administered activities of RAI must be balanced against uncertain
long-term benefits. If empiric RAI therapy is given and the posttherapy scan is negative, the
patient should be considered to have RAI-refractory disease and no further RAI therapy
should be administered.
ATA GUIDELNES 2015

40. REFRACTARIEDAD AL YODO

41. ¿Qué paciente es refractario al yodo?
PACIENTE A
Varón de 20 años
Ca papilar de tiroides
Metástasis miliares
pulmonares
Tto: 650 mCi
Tg se ha duplicado en 6m
EE Rx
PACIENTE B
Mujer de 65 años
Ca papilar variedad células
tachuela
Enf cervical irresecable
Mtx pulmonares EE
Tto: 400 mCi
FDG +, MIBG neg
Tg 60 ng/mL
Crecimiento del 20% en 12
meses de enf cervical
PACIENTE C
Varón de 45 años
Ca folicular
Tg 24 ng/mL
Mtx pulmonares que han
aumentado de 25 a 29 mm
en 4 meses tras tto con I131
(12%)

42. ATA GUIDELINES 2015

45. Wassermann J. Outcomes and Prognostic Factors in Radioiodine Refractory Differentiated Thyroid
Carcinomas. Oncologist. 2016;21(1):50-58. doi:10.1634/theoncologist.2015-0107
OS
9.8
años
OS
8.8
años
OS
8.8
años
OS
2.3
años

46. ATA GUIDELNES 2015

47. ¿A cuál de estos pacientes administrarías tto
sistémico?
PACIENTE A
Varón de 20 años
Ca papilar de tiroides
Metástasis miliares
pulmonares
Tto: 650 mCi
Tg se ha duplicado en 6m
EE Rx
PACIENTE B
Mujer de 65 años
Ca papilar variedad células
tachuela
Enf cervical irresecable
Mtx pulmonares EE
Tto: 400 mCi
FDG +, MIBG neg
Tg 60 ng/mL
Crecimiento del 20% en 12
meses de enf cervical
PACIENTE C
Varón de 45 años
Ca folicular
Tg 24 ng/mL
Mtx pulmonares que han
aumentado de 25 a 29 mm
en 4 meses tras tto con I131
(12%)

48. COMITÉ
MULTIDISCIPLINAR

49. MUCHAS GRACIAS