A 28-year-old woman undergoes surgery for a 3 cm papillary thyroid microcarcinoma variant with extensive extrathyroidal extension and bilateral central neck nodes. Post-operatively, the most appropriate radioiodine ablation strategy involves which TSH stimulation method and target remnant ablation dose?
- A Thyroid hormone withdrawal to TSH >30 mIU/L; 30 mCi I-131
- B Thyroid hormone withdrawal; 150–200 mCi I-131 for high-risk disease with nodal metastases ✓
- C Recombinant human TSH (rhTSH) injection; 100 mCi I-131
- D rhTSH injection; 30 mCi I-131 is equivalent to THW for high-risk patients
Explanation
For high-risk papillary thyroid carcinoma (extrathyroidal extension, multiple positive nodes), ATA guidelines recommend high-dose I-131 (100–200 mCi) combined with thyroid hormone withdrawal (THW) to achieve TSH >30 mIU/L, as rhTSH has not been validated as equivalent for high-risk adjuvant therapy in randomised trials. The ESTIMABL and HiLo trials established that rhTSH plus 30 mCi is equivalent to THW plus 100 mCi for low-risk remnant ablation only. This patient's extrathyroidal extension and bilateral nodal disease categorise her as high-risk, warranting THW with high-activity I-131.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.