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Introduction External beam radiation therapy is one of the important treatment methods for thyroid cancer.
Although its adjuvant therapy role in differentiated thyroid cancer (DTC) is controversial, with the development of technology and the improvement of equipment, the complications of external beam radiation therapy have been significantly reduced.
, so that its status in the treatment of thyroid cancer has been paid attention to once again 1
.
In order to promote the multidisciplinary diagnosis and treatment (MDT) of DTC and standardize the application of external beam radiation therapy in the diagnosis and treatment of DTC, Chinese multidisciplinary experts have jointly compiled the "Chinese Society of Clinical Oncology (CSCO) Diagnosis and Treatment of Differentiated Thyroid Cancer" based on evidence-based medicine and China's national conditions.
Guidelines (2021)" (hereinafter referred to as "Guidelines")
.
Imailong specially invited Professor Hou Xiaorong of Peking Union Medical College Hospital to interpret the Chinese and external radiation therapy chapters of the "Guide" for us
.
Expert Profile Professor Hou Xiaorong, Ph.
D.
, Associate Professor, Department of Radiotherapy, Peking Union Medical College Hospital, Master Supervisor Vice-chairman of the Youth Committee of the Therapeutic Physician Branch Member of the Chinese Society of Clinical Oncology Gynecological Oncology Expert Committee Member of the Standing Committee of the Thyroid Cancer Clinical Research Collaborative Group of the Chinese Society of Clinical Oncology Technician) Branch Director External beam therapy is helpful for local and regional control of postoperative high-risk, persistent/recurrent and metastatic DTC patients, and can play a positive supplementary role in the overall treatment of patients 2
.
The Guidelines divide external beam radiation therapy into two levels, local residual/recurrent lesions and metastatic lesions (lung metastases, bone metastases, and brain metastases, etc.
) according to the location of the lesions
.
Table 1 Recommendations for external beam therapy in the Guidelines Recommendation: External beam therapy can be applied to unresectable or iodine-refractory local residual/recurrent lesions The use of external beam therapy in DTC has been controversial 1
.
In the "Guidelines for the Diagnosis and Treatment of Thyroid Nodules and Differentiated Thyroid Cancer in Adults (2015)" issued by the American Thyroid Association (ATA), ATA believes that external beam radiation therapy is only suitable for patients with locally advanced or distant metastatic thyroid cancer.
Routine adjuvant external beam therapy to the neck has no effect in patients with DTC after primary complete tumor resection 1,3
.
In the "Guidelines", CSCO believes that external beam therapy can be applied to: (1) patients with residual tumors that cannot be surgically removed and cannot be controlled by radioactive iodine (RAI) alone; (2) patients with residual or recurrent lesions that do not receive iodine after surgery
.
It should be noted, however, that external beam therapy improves local recurrence-free survival, but has no significant effect on overall survival 2
.
Interpretation 2: Comprehensive consideration of the irradiation area and dose design factors such as pathological type, lesion range, and lymph node invasion degree are important influencing factors for the design of the irradiation area for thyroid cancer neck external beam radiation therapy 1
.
For DTC patients, the irradiation range is mainly divided into small field irradiation (including thyroid bed recurrence or residual tumor area) and large field irradiation (including thyroid bed recurrence and regional lymphatic drainage area) 2
.
Although large field irradiation can be used for prophylactic irradiation of the lymphatic drainage area, the mainstream opinion is still more in favor of small field irradiation
.
In terms of dose selection, the "Guidelines" recommend that, on the premise of ensuring patient safety, a sufficiently high external beam therapy dose should be given to the general tumor area of the patient
.
At present, the "Guide" recommends that the external radiation therapy dose for the general tumor area is 60-70 Gy, and the clinical target area is 50-60 Gy
.
Interpretation 3: The advancement of external beam therapy technology drives improvement of therapeutic effects and reduction of side effects With the development of half a century, external beam therapy technology has gradually developed from traditional two-dimensional treatment to multi-dimensional, three-dimensional, and precise treatment
.
The advent of technologies such as Intensity Modulated Radiation Therapy (IMRT), Image-Guided Radiation Therapy (IGRT) and Stereotactic Radiation Therapy (SBRT) has increased the therapeutic dose of the target area, protected normal tissues and organs, and reduced the toxic and side effects of treatment
.
In the Guidelines, the CSCO considers IMRT as the preferred radiotherapy technique 2
.
Recommendation: External beam radiation therapy can be applied to metastatic lesions Interpretation 1: According to the number of metastatic lesions, choose a treatment plan for lung metastases Involvement, local therapy can bring survival benefit to patients with oligometastatic disease
.
The lungs are a common site of DTC metastases
.
For patients with pulmonary oligometastases, SBRT can bring good clinical efficacy under the premise of sufficient biological dose, while for diffuse multiple pulmonary metastases, external beam therapy can be used as an alternative treatment 2
.
Interpretation 2: Improve pain symptoms and reduce bone-related events External radiation therapy is one of the main treatment methods for bone metastases.
It can reduce lesions, reduce the pressure and destruction of periosteum and bone marrow cavity, effectively relieve pain symptoms of patients, reduce and delay pathology fractures and other events, and improve the quality of life of patients
.
In addition, for isolated, symptomatic metastases, external beam therapy can be used as a supplementary treatment after surgical resection 2
.
Interpretation 3: Weigh the risks and benefits, and consider surgery and external beam radiation therapy.
Due to the existence of the blood-brain barrier, drug therapy is limited, and 131I therapy can cause tissue edema around the tumor.
Therefore, external beam therapy and surgery are DTC brain metastases.
main treatment
.
Although surgery can quickly resolve mass effects, clinicians should consider the risks and value of surgery
.
With the development of radiotherapy technology, external radiation therapy can also obtain similar therapeutic effects as surgery
.
For patients with multiple intracranial metastases or obvious symptoms of cerebral edema in tumor volume, clinicians should also strengthen adjuvant therapy such as dehydration and intracranial pressure reduction 2
.
Interpretation 4: Palliative treatment, relieve symptoms External beam therapy is suitable for palliative treatment when the tumor does not take iodine or the 131I treatment effect is poor and iodine-refractory state occurs.
It can improve the patient's symptoms such as local compression or pain, and improve the patient's quality of life 2
.
References: 1.
Dong Fang, Xue Jincai, Wang Yunsheng, Liu Qinjiang.
Changes in external beam radiation therapy for thyroid cancer [J].
International Journal of Oncology, 2019(11): 641-648.
2.
Guidelines Working Committee of the Chinese Society of Clinical Oncology.
Chinese Society of Oncology (CSCO) Guidelines for the Diagnosis and Treatment of Differentiated Thyroid Cancer (2021) [M].
People's Health Publishing House 3.
Haugen BR, Alexander EK, Bible KC, et al.
2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer[J].
Thyroid.
2016;26(1):1-133.
Although its adjuvant therapy role in differentiated thyroid cancer (DTC) is controversial, with the development of technology and the improvement of equipment, the complications of external beam radiation therapy have been significantly reduced.
, so that its status in the treatment of thyroid cancer has been paid attention to once again 1
.
In order to promote the multidisciplinary diagnosis and treatment (MDT) of DTC and standardize the application of external beam radiation therapy in the diagnosis and treatment of DTC, Chinese multidisciplinary experts have jointly compiled the "Chinese Society of Clinical Oncology (CSCO) Diagnosis and Treatment of Differentiated Thyroid Cancer" based on evidence-based medicine and China's national conditions.
Guidelines (2021)" (hereinafter referred to as "Guidelines")
.
Imailong specially invited Professor Hou Xiaorong of Peking Union Medical College Hospital to interpret the Chinese and external radiation therapy chapters of the "Guide" for us
.
Expert Profile Professor Hou Xiaorong, Ph.
D.
, Associate Professor, Department of Radiotherapy, Peking Union Medical College Hospital, Master Supervisor Vice-chairman of the Youth Committee of the Therapeutic Physician Branch Member of the Chinese Society of Clinical Oncology Gynecological Oncology Expert Committee Member of the Standing Committee of the Thyroid Cancer Clinical Research Collaborative Group of the Chinese Society of Clinical Oncology Technician) Branch Director External beam therapy is helpful for local and regional control of postoperative high-risk, persistent/recurrent and metastatic DTC patients, and can play a positive supplementary role in the overall treatment of patients 2
.
The Guidelines divide external beam radiation therapy into two levels, local residual/recurrent lesions and metastatic lesions (lung metastases, bone metastases, and brain metastases, etc.
) according to the location of the lesions
.
Table 1 Recommendations for external beam therapy in the Guidelines Recommendation: External beam therapy can be applied to unresectable or iodine-refractory local residual/recurrent lesions The use of external beam therapy in DTC has been controversial 1
.
In the "Guidelines for the Diagnosis and Treatment of Thyroid Nodules and Differentiated Thyroid Cancer in Adults (2015)" issued by the American Thyroid Association (ATA), ATA believes that external beam radiation therapy is only suitable for patients with locally advanced or distant metastatic thyroid cancer.
Routine adjuvant external beam therapy to the neck has no effect in patients with DTC after primary complete tumor resection 1,3
.
In the "Guidelines", CSCO believes that external beam therapy can be applied to: (1) patients with residual tumors that cannot be surgically removed and cannot be controlled by radioactive iodine (RAI) alone; (2) patients with residual or recurrent lesions that do not receive iodine after surgery
.
It should be noted, however, that external beam therapy improves local recurrence-free survival, but has no significant effect on overall survival 2
.
Interpretation 2: Comprehensive consideration of the irradiation area and dose design factors such as pathological type, lesion range, and lymph node invasion degree are important influencing factors for the design of the irradiation area for thyroid cancer neck external beam radiation therapy 1
.
For DTC patients, the irradiation range is mainly divided into small field irradiation (including thyroid bed recurrence or residual tumor area) and large field irradiation (including thyroid bed recurrence and regional lymphatic drainage area) 2
.
Although large field irradiation can be used for prophylactic irradiation of the lymphatic drainage area, the mainstream opinion is still more in favor of small field irradiation
.
In terms of dose selection, the "Guidelines" recommend that, on the premise of ensuring patient safety, a sufficiently high external beam therapy dose should be given to the general tumor area of the patient
.
At present, the "Guide" recommends that the external radiation therapy dose for the general tumor area is 60-70 Gy, and the clinical target area is 50-60 Gy
.
Interpretation 3: The advancement of external beam therapy technology drives improvement of therapeutic effects and reduction of side effects With the development of half a century, external beam therapy technology has gradually developed from traditional two-dimensional treatment to multi-dimensional, three-dimensional, and precise treatment
.
The advent of technologies such as Intensity Modulated Radiation Therapy (IMRT), Image-Guided Radiation Therapy (IGRT) and Stereotactic Radiation Therapy (SBRT) has increased the therapeutic dose of the target area, protected normal tissues and organs, and reduced the toxic and side effects of treatment
.
In the Guidelines, the CSCO considers IMRT as the preferred radiotherapy technique 2
.
Recommendation: External beam radiation therapy can be applied to metastatic lesions Interpretation 1: According to the number of metastatic lesions, choose a treatment plan for lung metastases Involvement, local therapy can bring survival benefit to patients with oligometastatic disease
.
The lungs are a common site of DTC metastases
.
For patients with pulmonary oligometastases, SBRT can bring good clinical efficacy under the premise of sufficient biological dose, while for diffuse multiple pulmonary metastases, external beam therapy can be used as an alternative treatment 2
.
Interpretation 2: Improve pain symptoms and reduce bone-related events External radiation therapy is one of the main treatment methods for bone metastases.
It can reduce lesions, reduce the pressure and destruction of periosteum and bone marrow cavity, effectively relieve pain symptoms of patients, reduce and delay pathology fractures and other events, and improve the quality of life of patients
.
In addition, for isolated, symptomatic metastases, external beam therapy can be used as a supplementary treatment after surgical resection 2
.
Interpretation 3: Weigh the risks and benefits, and consider surgery and external beam radiation therapy.
Due to the existence of the blood-brain barrier, drug therapy is limited, and 131I therapy can cause tissue edema around the tumor.
Therefore, external beam therapy and surgery are DTC brain metastases.
main treatment
.
Although surgery can quickly resolve mass effects, clinicians should consider the risks and value of surgery
.
With the development of radiotherapy technology, external radiation therapy can also obtain similar therapeutic effects as surgery
.
For patients with multiple intracranial metastases or obvious symptoms of cerebral edema in tumor volume, clinicians should also strengthen adjuvant therapy such as dehydration and intracranial pressure reduction 2
.
Interpretation 4: Palliative treatment, relieve symptoms External beam therapy is suitable for palliative treatment when the tumor does not take iodine or the 131I treatment effect is poor and iodine-refractory state occurs.
It can improve the patient's symptoms such as local compression or pain, and improve the patient's quality of life 2
.
References: 1.
Dong Fang, Xue Jincai, Wang Yunsheng, Liu Qinjiang.
Changes in external beam radiation therapy for thyroid cancer [J].
International Journal of Oncology, 2019(11): 641-648.
2.
Guidelines Working Committee of the Chinese Society of Clinical Oncology.
Chinese Society of Oncology (CSCO) Guidelines for the Diagnosis and Treatment of Differentiated Thyroid Cancer (2021) [M].
People's Health Publishing House 3.
Haugen BR, Alexander EK, Bible KC, et al.
2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer[J].
Thyroid.
2016;26(1):1-133.
