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The success of multimodality treatment in metastatic medullary thyroid cancer

 

Bliss Anderson1, Kate Newbold2 & Daniel Morganstein1,2, 1Department of Endocrinology, Chelsea and Westminster Hospital, 2Thyroid Unit, The Royal Marsden Hospital

 

Introduction: Although medullary thyroid cancer can have a good prognosis even in the presence of metastatic disease, there are some patients who develop progressive metastatic disease that is life limiting. We describe a patient with advanced disease who has undergone multimodality treatment.

 

Case: A 43 year old gentleman presented with a neck mass in 2005. He was diagnosed with medullary thyroid cancer and managed with a total thyroidectomy. Genetic testing confirmed that it was sporadic. Subsequent recurrence of the medullary thyroid cancer meant that a radical neck dissection and removal of a paratracheal mass was performed in 2012. 65Gy in 30 fractions of radiotherapy was applied to the left side of the neck and thyroid mass with another 54 Gy in 30 fractions applied to the right side.

 

In February 2013, a Computer Tomography (CT) scan performed showed improved thyroid disease but progression of metastases with new lesions in the lungs, left parietal lobe and cerebellum and therefore whole brain radiotherapy was given. In April 2013, the patient was commenced on treatment with vandetanib which was well tolerated apart from some diarrhoea that was successfully managed with loperamide. Whilst another CT scan in February 2014 showed stable disease, vandetanib was stopped for a two week period due to reduced appetite and low mood in June 2014.

The patient represented in January 2016 with neurological symptoms and a CT head demonstrated a basal ganglia infarction, likely to represent a transient ischaemic attack. One year later a repeat staging CT found further disease progression, vandetanib was therefore stopped and instead the patient was entered into a clinical trial of nintedanib. Progression of liver and further brain metastases resulted in the patient being unblinded. As the patient was already found to already be in the treatment arm, he underwent re-irradiation of the brain from March to May 2017. Following this, cabozantinib was commenced on a compassionate funding basis giving a further six months of disease control. The patientís disease has now progressed in multiple sites and there are no further disease modifying options.

 

Discussion: This case illustrates that multiple lines of tyrosine kinase inhibitors in combination with locally ablative treatment can prolong progression-free survival and provide symptom control in metastatic medullary thyroid cancer.