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Following total or near-total thyroidectomy, patients with differentiated thyroid carcinoma receive an RAI neck and whole-body scan, either while hypothyroid, or after thyrotropin administration In patients with visible RAI uptake, those with stage II IV cancer should be treated with adjuvant 131I therapy, when possible The use of RAI therapy for patients with stage I differentiated thyroid cancer (with residual thyroid bed RAI uptake) is controversial; there has been no demonstrable improvement in survival in this group of patients following RAI therapy, although RAI therapy reduces the risk of local recurrence Some groups advocate RAI therapy for patients with stage I disease whose primary tumor was over 1 cm in diameter Patients must have demonstrated uptake of RAI on diagnostic scanning to warrant RAI therapy For patients who have 131I therapy, the dose of 131I for thyroid remnant ablation (residual normal thyroid with perhaps thyroid cancer in the thyroid bed) in those with no nodal involvement is 30 100 mCi, with the higher doses given to patients with large primary tumors or tumors at the surgical margin Patients with local lymph node involvement typically receive 100 mCi of 131I; patients with more extensive neck node involvement or distant metastases receive 150 200 mCi of 131I Prior to 131I therapy, patients must be allowed to become hypothyroid, since high TSH levels stimulate thyroid cancer cells to actively absorb more iodine, and hypothyroidism reduces the renal clearance of iodine Being hypothyroid is uncomfortable for most patients Because levothyroxine (T4) has a much longer half-life than T3, the following protocol is suggested to prepare patients for 131I therapy: 8 weeks prior to 131 I therapy, levothyroxine replacement therapy is stopped and T3 (Cytomel) is substituted at a dose of 125 mcg orally twice daily; 6 weeks prior to 131I therapy, the Cytomel is increased to 25 mcg orally twice daily; 16 days prior to 131I therapy, the Cytomel is discontinued.

thyroid carcinoma does not respond to 131I therapy and is resistant to chemotherapy Patients with thyroid MALT lymphomas have a low risk of recurrence after simple thyroidectomy Patients with other thyroid lymphomas are best treated with external radiation therapy; chemotherapy is added for extensive lymphoma Patients with systemic lymphomas involving the thyroid are usually treated with chemotherapy Patients with medullary thyroid carcinoma are treated surgically; repeated neck dissections are often required over time Medullary thyroid carcinomas do not respond to 131I therapy Medullary thyroid carcinoma is generally resistant to chemotherapy, although there have been encouraging preliminary results from a clinical trial with a second-generation inhibitor of vascular endothelial growth factor receptors (VEGFR) Patients with medullary thyroid carcinoma are advised to have genetic testing for ret protooncogene mutations Patients who are discovered to have a germline mutation may require surveillance for other manifestations of MEN; genetic testing of first-degree relatives is also advisable It is advisable that children with a ret protooncogene mutation have a prophylactic total thyroidectomy, ideally by age 6 years (MEN 2A) or at age 6 months (MEN 2B) Medullary thyroid carcinoma does not take up 131I

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