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Recombinant TSH-Stimulated, Radioguided Differentiated Thyroid Carcinoma Surgery

Department of Radiology, Nuclear Medicine Section, Marshfield Clinic, Marshfield, Wisconsin

Steven B. Standiford, MD

Surgery Oncology Section, Marshfield Clinic, Marshfield, Wisconsin

Marjorie E. Starkman, MD

Department of Internal Medicine, Endocrinology Section, Marshfield Clinic, Marshfield, Wisconsin

John Gough, MS, CHP

Swedish Medical Center, Seattle, Washington

REPRINT REQUESTS: Michael E. Spieth, MD, Department of Radiology, Section of Nuclear Medicine, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, Wisconsin 54449, Telephone: 715-387-7787, Fax: 715-387-7775, Email: spieth.michael{at}marshfieldclinic.org

A novel approach to locating and surgically resecting occult metastatic foci in a 25-year-old female with a history of total thyroidectomy for differentiated thyroid carcinoma was attempted. Two iodine-131 (¹³¹I) body scans were performed: one after the patient underwent a 2–3 week thyroxine withdrawal, and another the following week utilizing recombinant TSH-stimulation. Then the patient was treated with 151 mCi of ¹³¹I, and 2 weeks later, without further hormonal manipulation, she had radioguided surgery. The two diagnostic ¹³¹I body scans were negative, but the post-therapy scan was positive. Two weeks later after pre-operative skin marking, radioguided surgery localized metastatic foci in the central compartment neck just dorsal to the suprasternal notch. No other foci were identified with the probe at surgery. At pathology, 2 of the 12 nodes were positive, as well as a 1 mm metastatic focus in the fat. Provocative imaging protocols, aggressive radioiodine therapy, and the novel use of radioguided surgery to attempt a cure in an ¹³¹I image-negative metastatic thyroid carcinoma patient was performed. No other cases using these combined diagnostic and therapeutic efforts have been reported in the literature.

Key Words: Iodine radioisotopes • Radioguided surgery • Thyroid neoplasms • Radiotherapy