Recurrent Disease

• Discussion of all recurrent and metastatic disease in the MDT which may need mul-tidisciplinary management of complex problems.

• PET scan should be available, especially for patients with raised thyroglobulin and negative scan.

• Surgery, radioiodine, external beam radiotherapy, and combinations are the main treatment options for recurrent disease; in a small proportion of patients embolization, redifferentiation therapy, and therapeutic radiolabeled octreotide may be of use.

• Radioactive iodine - it is preferable to keep the cumulative radioiodine doses to <20GBq (Schlumberger, [50] especially if the patient has also had external beam radiotherapy) or at least below 40 GBq if clinical situation allows. The time interval between repeated radioiodine treatment doses should be kept to about 12 months and not less than 6 months if possible unless there is rapidly progressive disease. This probably minimizes long-term side effects of radioiodine. Fixed dose (5-7 GBq) is common or dosimetry-based doses can be used (Chapters 1,15).

• External beam radiotherapy - three-dimensional conformal radiotherapy should be used in appropriate cases as an adjuvant (if gross macroscopic and microscopic residual disease and further surgery is not suitable) or for recurrent cancer in the neck if further surgery or radioactive iodine is not appropriate. Dose: 50-60 Gy over 5-6 weeks or its radio-biological equivalent. Up to 66 Gy to large volume disease if necessary. Maximum spinal cord dose 46 Gy in 2 Gy fractions or equivalent. Field size - (depending on cases): Superior - tip of the mastoid or hyoid. Inferior - carina or suprasternal notch. Lateral - whole width of the neck or tumor with margin. Intensity modulated radiotherapy (IMRT) may be used in the future to improve dose distribution (Chapters 1,15).

• Raised thyroglobulin and negative iodine scan (Chapter 18).

Check strict preparation for the scanning procedure and exclude false-negative scan and false-positive thyroglobulin (presence of heterophil antibodies and residual normal thyroid remnant). Thy-roglobulin assessment quite soon after high dose radioiodine treatment might also give high levels which gradually disappear over months, sometimes a year or two.

Routine empirical high dose iodine treatment - Schlumberger, [51] Pineda and others - effective in some cases (Chapter 20).

Selective high dose iodine therapy if necessary after further investigation with neck ultrasound, CT scan, PET etc.- Mazzaferri, Pacini, Wartofsky (see Chapter 1).

• Chemotherapy - Adriamycin or Adriamycin and platinum are active agents. Raised TSH can be used (see Chapter 30). This is for iodine-negative advanced disease when no other options are available. Others are under investigation, for example liposomal anthracycline etc. [33].

• Molecular targeted therapy - small molecule tyrosine kinase inhibitors (gefitinib or Iressa) are under investigation for endstage radioiodine refractory disease [33].

• Although trials and studies are rare, efforts should be made to design and take part in collaborative clinical and translational studies [39].

• Specialist palliative care and symptom control for end-stage disease and support from clinical psychologists.

Summary

Thyroid cancer should be managed by a multi-disciplinary team of experts. This can only provide the best possible care for individual patients for this rare and highly curable cancer.

This does take place in many countries and in recent years this has been made more formalized in the UK as a part of the NHS National Cancer Plan.

Recommendations have been made by NICE (IOG) about the detailed structure and function of a multidisciplinary team specializing in thyroid cancer management in the UK, which should treat a population base of approximately 1 million.

Every MDT in the UK has to comply with the highest possible standards and one of the most comprehensive list (MCS) of these has also been published for most cancers (thyroid awaited). The unique feature is that compliance with these standards is auditable and will be monitored while support will be provided to achieve these objectives.

Treatment should be based on evidence-based guidelines, which should be regularly reviewed, and outcomes should be regularly monitored.

The members of the team should have continuing professional development and should be engaged in regular audit and participation in clinical studies and trials.

The patients must always be given proper information and support and should take part in the decision-making process.

The essential theme is that the treatment should be patient focused and that the service provided should be high quality, fast track, caring and cost-effective to achieve the highest cure rate and the best possible quality of life for our patients.

This particular detailed framework is clearly not relevant for all countries but there may be common themes and it can initiate some helpful discussions, providing a basis for sharing good practice, and indeed can lead to the development of a model for international best practice.

Postscript - Tableau No IV; Lozenge Composition with Red, Gray, Blue, Yellow, and Black by Piet Mondrian

Finally MDT management of thyroid cancer and other cancers is evidenced-based science but it is also an art. Individual team members' contributions develop and compose the most effective and comprehensive treatment plan for each patient (delivering it with utmost care, humanity, and compassion which in itself is an art), as is portrayed in the following famous painting by Piet Mondrian (Figure 3.1).

Figure 3.1 Piet Mondrian.Tableau No. IV; Lozenge Composition with Red, Gray, Blue, Yellow, and Black, Gift of Herbert and Nannette Rothschild, Image © 2005 Board of Trustees, National Gallery of Art, Washington, c. 1924/1925, oil on canvas on hardboard.

Acknowledgments. The author gratefully acknowledges relying on and quoting from Department of Health publications and NICE IOG on the subject and especially using the summary table (Table 3.1), which has been modified to design thyroid MDT standards.

The author is very grateful to Professor Maz-zaferri, Professor Pacini, Dr Baudin, Professor Reiners, Professor Bal, and Professor Mitchell for helpful information and to the members of the Northern Cancer Network thyroid cancer team for helpful discussions.

Grateful thanks to Mrs Paula Simpson and Mrs Gina Brailey for the preparation of this manuscript.

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