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Differentiated thyroid cancer refractory to standard treatment: Chemotherapy

Author
Steven I Sherman, MD
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD

INTRODUCTION

The treatment of most patients with differentiated thyroid cancer (DTC; both papillary [PTC] and follicular [FTC] histologies) includes surgery, thyroid hormone therapy, and selective use of radioactive iodine. When metastatic disease occurs, radioactive iodine can be curative in a minority of patients, and thyroid-stimulating hormone (TSH)-suppressive thyroid hormone therapy can help to slow the pace of the disease. In addition, external radiotherapy may be useful in some patients. (See "Differentiated thyroid cancer: Overview of management" and "Differentiated thyroid cancer: Radioiodine treatment" and "Differentiated thyroid cancer: External beam radiotherapy".)

However, for those patients with metastatic DTC that progresses despite radioiodine, TSH-suppressive thyroid hormone therapy, and external beam radiotherapy (EBRT), treatment options have historically been limited. New approaches based upon application of targeted chemotherapies are emerging as effective alternatives for progressive disease. Current and experimental chemotherapies for advanced DTC will be reviewed here. Chemotherapies for medullary and anaplastic thyroid cancers are discussed separately. (See "Medullary thyroid cancer: Chemotherapy and immunotherapy" and "Anaplastic thyroid cancer".)

TREATMENT OPTIONS

For patients with metastatic differentiated thyroid cancer (DTC) that persists despite radioiodine, thyroid-stimulating hormone (TSH)-suppressive thyroid hormone therapy, and external radiotherapy, treatment options include observation, kinase inhibitors that primarily target angiogenesis, and traditional cytotoxic chemotherapy.

The availability of kinase inhibitors that can stabilize progressive metastatic disease has changed the standard approach to treating patients whose disease no longer responds to radioiodine and TSH-suppressive hormone therapy [1,2]. Although it may take many months before radiographic response becomes evident, targeting angiogenesis (and specifically vascular endothelial growth factor receptor [VEGFR] signaling pathways) has produced the most impressive clinical responses to date in DTC.

However, these drugs are disease-modifying agents, usually tumoristatic rather than tumoricidal, and no published study has demonstrated that these agents improve overall survival. In addition, these newer “targeted therapies” have significant toxicities and, therefore, it is important to limit the use of systemic treatments to patients at significant risk for morbidity or mortality due to progressive metastatic disease. Patients treated with systemic agents should have a baseline performance status sufficiently functional to tolerate these interventions, such as being ambulatory at least 50 percent of the day (Eastern Cooperative Oncology Group [ECOG] performance status 2 or better).

                             

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Literature review current through: Nov 2016. | This topic last updated: Thu Jun 02 00:00:00 GMT+00:00 2016.
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