Can We Discharge Dynamically Risk-Stratified Low-Risk (Excellent Response to Treatment) Thyroid Cancer Patients After 5 Years of Follow-Up?

AIMS: The 2014 British Thyroid Association thyroid cancer guidelines recommend lifelong follow-up of thyroid cancer patients. This is probably unnecessary, can cause patient anxiety, is time consuming and places significant demand on National Health Service resources. It has been suggested that low-risk differentiated thyroid cancer (DTC) patients could be discharged to primary care once they are 5 years from diagnosis and treatment. The aim of this study was to investigate the potential safety of this practice. MATERIALS AND METHODS: In total, 756 patients with dynamically risk-stratified (DRS) low-risk/excellent response to treatment DTC treated over 2001-2013 in the Leeds region were followed after diagnostic surgery and the recurrence rate calculated. RESULTS: The median follow-up time was nearly 10 years (5-17 years). Radiological recurrence occurred in 13/756 (1.7%) patients and was always preceded by raised thyroglobulin/ thyroglobulin antibody levels. In all 13 patients elevation of thyroglobulin occurred within 5 years of diagnosis. Two additional patients were found to have rising thyroglobulin at almost 9 and 10.5 years from diagnosis, although to date radiological recurrence has not been detected. Assuming these two patients developed recurrence with longer duration of follow-up, then 0.26% (2/756) of patients would not have their recurrence discovered within 5 years of diagnosis. To detect 100% of patients with a putative recurrence in our cohort would require 10.5 years of follow-up. Four patients had transiently raised thyroglobulin, which became undetectable within 2 years (in three patients), without any treatment and radiological recurrence was not discovered. CONCLUSION: Discharge of DRS low-risk DTC patients to primary care after 5 years of secondary care follow-up is reasonable, accepting that late recurrence may occur in a very small minority of individuals (0.26%, ∼1:400). A more cautious approach would be to continue monitoring for 10 years, although the frequency of assessments could be reduced with increasing duration of follow-up.

Ten Year Experience of Radioiodine Dosimetry: is it Useful in the Management of Metastatic Differentiated Thyroid Cancer?

AIMS: When a fixed activity of radioiodine is given for differentiated thyroid cancer (DTC), absorbed doses of radioiodine can vary widely and are not usually measured. Leeds Cancer Centre has routinely used a form of lesion-specific dosimetry for radioiodine patients. This study investigated if the results of dosimetry influenced treatment decisions for patients with advanced DTC. MATERIALS AND METHODS: Since 2005, patients with regionally advanced/metastatic DTC, who underwent radioiodine treatment together with dosimetry, were included in this study. Patients were excluded if their radioiodine post-treatment scan showed no abnormal uptake. Dosimetry was calculated using images taken 2, 3 and 7 days post-radioiodine. Regions of interest were drawn around lesions that required dosimetry and a time-dose activity curve was created. The total cumulative activity was equal to the area under the curve. Each patient's results were prospectively assessed by their oncologist regarding the usefulness of dosimetry in making management decisions. RESULTS: Thirty patients were studied and underwent 102 admissions of radioiodine between them. Dosimetry was carried out during 83 of 102 admissions. An absorbed dose of >20 Gy was taken as significant from dosimetry calculations, following which further radioiodine was considered. In 80% of patients, dosimetry was found to be useful when making treatment decisions. Only on 1/19 admissions did dosimetry calculate a minimum dose above 20 Gy in patients who had a total of four or more admissions for radioiodine. Ten per cent (3/30) had a complete response to radioiodine, both biochemically and radiologically, with a median follow-up of 6.7 months. Thirty-three per cent had a partial response/stable disease to radioiodine. The remainder had progressive disease. The decision to discontinue radioiodine therapy was often based on dosimetry and thyroglobulin results. Dosimetry was very useful for patients with thyroglobulin antibodies. CONCLUSION: Only 10% had a complete response. Therefore, a significant number of patients became refractory to radioiodine during a course of repeat admissions for treatment. Dosimetry (often together with thyroglobulin and anatomical scans) helped to identify these patients to avoid further futile radioiodine therapy.

Should we routinely offer a second admission for radioiodine to patients with high-risk differentiated thyroid cancer?

AIMS: To assess whether an elective second admission for radioiodine is useful for patients with high-risk differentiated thyroid cancer (DTC). MATERIALS AND METHODS: A retrospective analysis was carried out on 47 high-risk DTC patients treated with a second admission for radioiodine at our centre during the 2007-2008 period. RESULTS: In 21 patients (45%), the surgeon described an incomplete resection. Twenty-six (55%) had surgical macroscopic complete resection, but cancer cells at the margin of excision histologically. Overall, at the second admission for radioiodine, 27 patients (57%) had a normal post-treatment scan and undetectable thyroid-stimulating hormone (TSH) stimulated thyroglobulin. Twenty patients (43%) had raised stimulated thyroglobulin at second admission for radioiodine, of whom only six (13%) had abnormal uptake (>0.1%) on the post-treatment scan. CONCLUSIONS: A second admission for radioiodine could have been avoided in most patients. Instead, information from stimulated thyroglobulin and a diagnostic radioiodine scan would have been sufficient to guide further management. This study also provides interesting outcome data on incompletely resected DTC.

Survival in high-grade glioma: a study of survival in patients unfit for or declining radiotherapy.

AIMS: To determine the survival of patients with high-grade glioma (HGG) and a poor prognosis in terms of age or performance status managed with best supportive care alone. METHODS: An analysis of survival was carried out on 123 patients with HGG declining or judged unfit to receive radiotherapy, on the basis of age or performance status, between February 1998 and October 2003. Karnofsky performance status (KPS), biopsy or resection or no surgery, attendance at clinic and reason for not receiving radiotherapy were prospectively recorded. RESULTS: Of the 123 patients, three were excluded from the analysis, as no outcome data were available. Median age was 66 years (range 29-91 years), and median KPS was 50 (range 30-100). All 120 patients included had died at the time of analysis. Overall median survival was 68 days (95% CI 56-85), range 2-294 days and interquartile range 35-123 days. Median survival of 22 patients declining radiotherapy was 75 days (95% CI 53-123), of 98 patients unfit for radiotherapy 67 days (95% CI 48-88); non-significant difference P = 0.36. Median survival of 26 patients undergoing biopsy was 95 days (95% CI 66-123), of 56 undergoing surgical resection 74 days (95% CI 47-93), and of 38 receiving no surgical intervention 59 days (95% CI 47-70); non-significant difference P = 0.16. CONCLUSION: For patients with HGG and a poor prognosis, in terms of age or performance status managed with best supportive care, survival is short. Survival may be too short to benefit from radiotherapy and possibly surgery.

Neuro-oncology practice in the UK.

The aim of the study was to determine current U.K. neuro-oncology practice. A questionnaire was sent to all U.K. clinical oncologists who treat primary brain tumours. Results were distributed to these doctors with an invitation to attend a workshop in September 2000 to debate areas of differing practice and to review the existing related evidence. A further workshop was held in May 2002. The questionnaire responses and discussion of controversial areas, including the management of high-grade gliomas, low-grade gliomas, meningiomas, pituitary adenomas and multiple-brain metastases are included in this paper.

Investigating the palliative efficacy of whole-brain radiotherapy for patients with multiple-brain metastases and poor prognostic features.

AIMS: Trials have shown that patients with multiple-brain metastases and poor prognostic features have a short median survival after whole-brain radiotherapy (WBRT). Quality of life (QoL) and other parameters to assess the palliative efficacy of WBRT have not previously been studied in this group of patients. We therefore attempted to do this. MATERIALS AND METHODS: We performed three studies between 1997 and 2001. The two later studies were designed according to the results from the preceding study. Each of them revealed the difficulties in studying this group of unwell patients with a short survival. RESULTS: Thirty-eight patients were studied. They had at least two of three poor prognostic features, such as Karnofsky performance status (KPS) < 70, over 60 years of age, and primary other than breast cancer. The overall median survival was 8 weeks (95% CI 6-10). Twenty-four patients had a KPS < 70 and a median survival of 6 weeks (95% CI 4-9). At 8 weeks after WBRT, 14 out of 15 surviving patients for whom data were obtained suffered deterioration in QoL scores, Barthel or KPS. Ten of the 38 patients (26%, 95% CI 13-43%) improved in at least one of these parameters during the assessment period. Only three out of 38 patients discontinued steroids after the radiotherapy. Side-effects of WBRT were common. All patients experienced alopecia and lethargy after radiotherapy. CONCLUSIONS: Further trials involving larger numbers of patients are necessary. These studies offer further information on the limited response rates to WBRT, side-effects and effects on QoL, which need to be discussed with patients before they accept or decline the offer of cranial irradiation.

Open access follow-up for lung cancer: patient and staff satisfaction.

The majority of patients with lung cancer have incurable disease from presentation and a survival measured in months. Treatments offered to these patients are aimed at the palliation of symptoms with either radiotherapy or chemotherapy, or with supportive measures. It has been traditional to offer regular outpatient follow-up after initial palliative treatment. Further treatment options, which may be limited, are usually reserved for the recurrence of troublesome symptoms. A pilot 'open access' lung cancer clinic has been set up. Rather than have regular follow-up at the hospital, patients who have completed initial palliative treatments are discharged to the community with follow-up by their general practitioner and Macmillan nurse. Review at the open access clinic can be arranged at short notice if requested by the patient, carers, general practitioner or Macmillan nurse. The outcomes and level of satisfaction of patients, their relatives and staff to this method of follow-up were found to be positive. Open access follow-up may be useful for many patients after the completion of initial palliative treatment.

The future of oncology training: from the trainees' perspective.

A fundamental step towards any potential integration of the specialties of medical and clinical oncology into a common faculty in the UK, is to establish a core curriculum of training in both cancer sciences and clinical cancer medicine for both specialties. A questionnaire was sent to all UK trainees in cancer medicine in March 1997 to establish a baseline of patterns of training and to gather information on the trainees' views regarding the future of oncology training. The results of this survey are presented along with suggestions for discussion on the future of oncology training.

Toxicity and dosimetry of fractionated total body irradiation prior to allogeneic bone marrow transplantation using a straightforward radiotherapy technique.

Since 1989, we have used a relatively straightforward technique for giving total body irradiation (TBI), using anterior and posterior parallel opposed fields with the arms and fists acting as compensators. The dosimetry, toxicity and outcome of 48 patients (26 adults, 22 children) treated with TBI using this technique have been audited. A dose of 14.4 Gy in eight fractions over 4 days was prescribed to all patients with an unrelated donor and 12 Gy in six fractions over 3 days to those with a sibling donor. From May 1994, all children received 14.4 Gy because of a recommendation from the United Kingdom Children's Cancer Study Group. The range of lung dosimetry was -6% to +7% when the dose was specified to the lung maximum. The trunk doses were all within +/-10% of the prescribed dose. Doses to other regions of the body were less homogeneous but clinically acceptable in that the minimum doses were never less than -10% of the prescribed dose. Mucositis was the most common side effect; its treatment with opioids was more frequent after 14.4 Gy than after 12 Gy (P=0.0004) and in adults than in children (P=0.01). No cataracts have yet been seen in these patients. The radiation was not found to be a proven cause of clinical pneumonitis, although there was one death due to interstitial pneumonitis, which was likely to have been caused by cytomegalovirus infection in which radiation pneumonitis could not be excluded. There were no other suspected TBI-related deaths. In conclusion, this straightforward technique achieved acceptable dosimetry and was well tolerated.

An audit of the management of malignant hypercalcaemia.

A protocol was designed to help junior doctors to manage patients with malignant hypercalcaemia (MH). Seventy-five patients received 30 mg, 60 mg or 90 mg doses of pamidronate, depending on their initial serum calcium level. Fifty-four (72%) patients achieved normocalcaemia (NC) within 5 days after a single infusion of pamidronate. A further ten (13%) patients reached NC after a second dose, and 11 (15%) remained hypercalcaemic until death. NC was maintained for a median duration of 24 days. Patients received, on average, 30 mg less pamidronate than that given in the manufacturer's dosing schedule. The protocol was considered effective, economical and practical in the routine management of MH.

Bone marrow infiltration by a parietal lobe grade III oligodendroglioma.

We report a patient with oligodendroglioma metastases 1 year after tumour debulking and postoperative radiotherapy to the parietal lobe primary. This treatment controlled the patient's tumour locally. Distant recurrence was manifest by back pain, weight loss and malaise. The serum alkaline phosphatase was raised and a bone scan showed generalized increased uptake. Bone marrow trephine revealed infiltration by oligodendroglioma. Bone marrow infiltration by gliomas is very rare. If the trephine had not been performed it might have been assumed that he had a disseminated second primary tumour.