@article{28f5ce7327274c7a8df4de1aa21d9029,
title = "Lenvatinib in multimodal therapy for unresectable radioactive iodine-na{\"i}ve differentiated thyroid cancer: A case report with literature review",
abstract = "Background: Patients with unresectable or metastatic differentiated thyroid carcinoma (DTC) are rare and require individualized therapy. This may require approaches not typically used in resectable disease. We report a patient treated with lenvatinib and external beam radiation therapy. Case: An 87-year-old woman presented with cT4N1aM1 papillary thyroid carcinoma with tracheal invasion. She was not a candidate for surgery, radioactive-iodine, or radiation, so a trial of lenvatinib was offered. Her tumor showed clinical, biochemical, and radiological response after 5 months of lenvatinib, and she subsequently received external beam radiation. She enjoys good quality of life without evidence of cancer progression off therapy 21 months post-initiation of treatment. Conclusion: Lenvatinib may be effective in RAI-na{\"i}ve advanced DTC patients as a component of individualized multimodal therapy when conventional options are not feasible.",
keywords = "cancer care, cancer management, cancer medicine, clinical observations, head and neck cancer, immunotherapy",
author = "Kim, {Hugh Andrew Jinwook} and Nichols, {Anthony Charles} and Ramanamurthy Rachakonda and Richard Inculet and Jinka Sathya and Irina Rachinsky and Eric Winquist",
note = "Funding Information: Eric Winquist has served in a consulting/advisory role for Amgen, Bayer, Eisai, Ipsen, Merck, and Roche; and received research funding (institution) from Roche/Genenetech, Merck, Pfizer, Eisai and Ayala Pharmaceuticals. The other authors have no disclosures. An 87-year-old female was referred to our cancer center for management of locally advanced and metastatic papillary thyroid carcinoma. She reported a six-month history of increasing stridor, shortness of breath, and hemoptysis, which prompted investigation with a biopsy of her left thyroid and computed tomography (CT) of the neck and chest. Imaging showed a 4.2 cm left thyroid mass indenting and displacing the cervical trachea, an enlarged left supraclavicular node, a 4.0 cm right adrenal mass, and bilateral pulmonary nodules suspicious for metastases (Figure 1). She was staged as cT4N1aM1, corresponding to stage IVB. Flexible nasopharyngoscopy visualized a sluggish left vocal cord. Thoracic surgery assessment with flexible bronchoscopy visualized extensive tumor invasion of the left anterior tracheal wall involving the cricoid cartilage, decreasing the tracheal diameter by approximately 50% (Figure 2). It was presumed that without treatment, airway closure and death would follow within 2 months. Given the location of the tumor, surgical management would require total laryngectomy in addition to total thyroidectomy and central neck dissection. The patient declined surgery due to her desire for voice preservation. She was not a candidate for RAI given her intact thyroid gland and nondebulked primary tumor. There was tepid enthusiasm for EBRT given the size of the treatment field. Lenvatinib was thus offered, with an understanding that it was being used under exceptional circumstances for a non-approved indication, and the patient gave informed consent to proceed with therapy (provided by Eisai Limited, Mississauga, Ontario, Canada). In view of her age and health status, the starting dose was lenvatinib 14 mg p.o. daily with a plan to dose-titrate based on tolerance.9 Initially the patient was monitored weekly, and lenvatinib was well-tolerated with gradual disappearance of stridor and dyspnea. After 1 month, treatment was interrupted for 2 weeks due to diverticulitis, then restarted at the same 14 mg dose. CT scan after 3 months of treatment demonstrated decrease in size of the left thyroid mass (2.9 cm), pulmonary nodules, and right adrenal mass (3.9 cm), compared to 2 months prior to treatment initiation (Figure 3A). Thyroglobulin rose from 54.6 μg/L to 408.9 ug/L and thyroid stimulating hormone (TSH) from 1.09 mIU/L to 6.72 mIU/L, and oral levothyroxine replacement 100 μg daily was initiated. After 5 months of lenvatinib, local therapy was discussed in anticipation of eventual treatment resistance. The patient remained reluctant to pursue voice-sacrificing surgery, and there had been no changes in recommendation regarding RAI, as the remnant normal thyroid remained large. Thus, 1 week after stopping lenvatinib, she received EBRT 50 Gy in 20 fractions to the thyroid, bilateral neck, and superior mediastinal nodes. She experienced moderately severe fatigue and radiation pharyngitis, which resolved over several months. Following EBRT, thyroglobulin was 25.7 μg/L and TSH 0.01 mIU/L, and CT showed stability of the thyroid mass (Figure 3B). In this context, lenvatinib was not restarted, and she has since been observed. At her last follow-up 2 years after initiating lenvatinib, she was very satisfied with her quality of life and had resumed her usual activities with only mild residual dysphagia from EBRT. Publisher Copyright: {\textcopyright} 2022 The Authors. Cancer Reports published by Wiley Periodicals LLC.",
year = "2022",
month = oct,
day = "1",
doi = "10.1002/cnr2.1654",
language = "English",
volume = "5",
journal = "Cancer Reports",
issn = "2573-8348",
publisher = "Wiley-Blackwell Publishing Ltd",
number = "10",
}
