Differenziertes Schilddrüsenkarzinom – Fortschritte bei der Radioiodablation

Zusammenfassung

Für die differenzierten Schilddrüsenkarzinome stellt die Radioiodablation eine Standardtherapie dar, eine Ausnahme bilden unifokale, sehr kleine papilläre Schilddrüsenkarzinome. Die erforderliche TSH-Stimulation wird entweder durch eine Schilddrüsenhormonkarenz über 2–3 Wochen oder über rekombinantes humanes TSH (rhTSH) hergestellt. Mit beiden Optionen werden hohe Ablationsraten erzielt. Die Radioiodablation mit Aktivitäten zwischen 1,8 und 3,7 GBq ¹³¹I erfolgt grundsätzlich einzeitig. Seit 2010 ist rhTSH in Europa für die Indikationen pT1-4, N0-1, cM0 zugelassen. Aus Beobachtungsstudien an Hochrisikopatienten hat sich kein Hinweis auf die Unterlegenheit eines der Verfahren ergeben. Die fehlende Einschränkung der Nierenclearance unter rhTSH reduziert die Blutaktivität von ¹³¹I und die Restkörperdosis. Sofern identische ¹³¹I-Aktivitäten unter endogener oder exogener Stimulation verglichen werden, fallen die akuten Nebenwirkungen unter rhTSH geringer aus. Bei der praktischen Durchführung führt ein „Minientzug” von Levothyroxin wenige Tage vor den rhTSH-Injektionen zur Iodverarmung, was für den Ablationserfolg bei der Anwendung niedriger ¹³¹I-Aktivitäten vorteilhaft zu sein scheint. Die Erfolgskontrolle der Ablation nach 3–6 Monaten mittels einer diagnostischen ¹³¹I-Ganzkörperszintigrafie sollte unter rhTSH durchgeführt werden. Dabei führt insbesondere der Thyreoglobulin (Tg)-Spiegel unter rhTSH zu einer Neubewertung des individuellen Risikos. Für das Patientenmonitoring sollten Tg-Assays der 2. Generation verwendet werden. Da die Radioiodablation im Langzeitverlauf die tumorassoziierte Mortalität, die Rate an Lokalrezidiven sowie die Wahrscheinlichkeit einer späteren Metastasierung günstig beeinflusst, besitzt die Ablation – basierend auf Metaanalysen – einen patientenrelevanten Nutzen.

Abstract

Ablative radioiodine therapy is the treatment of choice in patients with differentiated thyroid cancer, the only exception being the unifocal, very small papillary thyroid cancer. The TSH-stimulation can be achieved by a waiting period for 2–3 weeks after thyroidectomy without medication or by the use of recombinant human TSH (rhTSH). Both options lead to high success rates. “Single dose cure” using activities between 1.85 and 3.7 GBq ¹³¹I is standard. Since 2010 rhTSH is approved by the EMA for the indications pT1-4, N0-1, cM0. Survey studies did not find any inferiority of ablation with rhTSH or iatrogenic hypothyroidism in the high-risk patient group. Renal clearance is not reduced after rhTSH administration, thus the ¹³¹I blood dose and the whole body doses are lower in patients under rhTSH. Comparing identical ¹³¹I activities after endogeneous or exogeneous stimulation, rhTSH will minimize the acute adverse effects of ¹³¹I. A short-term withdrawal of levothyroxine some days before rhTSH-injection lowers the iodine plasma level, which may be advantageous for the ablation success if lower ¹³¹I activities are used. A rhTSH-based diagnostic ¹³¹I whole-body scintigraphy 3–6 months after ablation is standard for therapy control. At this time, the rhTSH-stimulated thyroglobulin-level is essential for a personalized risk stratification. Tg-measurements by a second generation assay should be used for follow-up care. Metaanalyses have shown that radioiodine ablation lowers the mortality rate, the risk of locoregional recurrences and the risk of late metastasizing. Therefore, ablation has shown a clear benefit.

Schlüsselwörter

differenziertes Schilddrüsenkarzinom - Radioiodablation - rekombinantes humanes TSH

Key words

differentiated thyroid cancer - radioiodine ablation - recombinant human TSH

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