Thyrogen Scans for Detecting Recurrent Thyroid Cancer

j Jamie E. Simon, RN, BA, BSN, OCN

ABSTRACT: Although the thyroid gland is a relatively small organ in the body, it plays a major role in health. Patients who are diagnosed with well-differentiated thyroid cancer can be effectively treated and have excellent rates of survival. After initial surgery and treatment with radioactive iodine ablation, these patients will require lifelong monitoring for recurrence of disease. The use of Thyrogen stimulated positron emission tomography/computed tomography scans plays an important role in long-term monitoring. The radiology nurses role as patient advocate is essential in helping patients have a successful journey through a Thyrogen study. (J Radiol Nurs 2012;31:144-148.) KEYWORDS: Nuclear medicine imaging; Thyroid cancer; Thyrogen scans; Radiology nursing.

INTRODUCTION Although thyroid cancer is uncommon, its incidence has been rising (Gwyther, 2012). The nuclear medicine studies to detect for recurrence of thyroid cancer are becoming more technologically advanced. A Thyrogen stimulated positron emission/computed tomography (PET-CT) scan has become a crucial study in detecting recurrence. The purpose of this article is to provide the radiology nurse with a basic understanding of the thyroid and its function, provide insight into treatment and monitoring of this disease, and educate radiology nurses in their role when a patient undergoes a Thyrogen stimulated PET-CT scan. THYROID GLAND The thyroid gland is a small gland situated in front of the neck and consists of two halves called lobes, which are joined together by a narrow band of thyroid tissue known as the isthmus. The weight of a normal thyroid gland is roughly 15 to 25 g in a normal adult although this can be altered signicantly by pathology (Janus,

Moore, Price, & Kasperbauer, 2012). Although relatively small and weighing less than one ounce, the thyroid gland has a major role in metabolism. Its function is to take the iodine from foods that are found in the bloodstream and convert it into thyroid hormones. Every cell in the body relies on the hormones the thyroid produces for regulation of their metabolism (Figure 1). THYROID HORMONES The two major hormones produced by the thyroid glands are thyroxine (T4) and triiodothyronine (T3). These hormones regulate metabolism, growth and development, and body temperature. Thyroid hormones are under the control of the pituitary gland (a small gland located at the base of the brain). When the levels of T3 and T4 drop too low, the pituitary gland produces thyroid-stimulating hormone (TSH), which in turn stimulates the thyroid gland to produce more hormones. Under the inuence of TSH, the thyroid will manufacture and secrete T3 and T4, thereby raising the blood levels of these hormones. The pituitary gland then senses this and responds by decreasing TSH production (Figure 2). This is a negative feedback system controlled by the hypothalamic-pituitary-thyroid (HPT) axis. To maintain homeostasis, systems must work in collaboration. The HPT axis is constantly active, monitoring, and responding to changing conditions to ensure equilibrium. A simple and practical example of a negative feedback system is a furnace and thermostat. Thyroid hormones are like heat. Imagining the thyroid gland as a furnace and TSH as a thermostatdwhen the heat
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Jamie E. Simon, RN, BA, BSN, OCN is in the Center for Advanced Medicine, Diagnostic Imaging Center, New Hyde Park, NY. This manuscript has not been previously presented and will not be submitted elsewhere. Corresponding author: Jamie E. Simon, Center for Advanced Medicine, Diagnostic Imaging Center, 450 Lakeville Road, New Hyde Park, NY 11042. E-mail: jasimo27@aol.com 1546-0843/$36.00 Copyright 2012 by the Association for Radiologic & Imaging Nursing. http://dx.doi.org/10.1016/j.jradnu.2012.06.001

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thyroid gland affects nearly all body functions, thyroid dysfunction has head to toe consequences (p. 23). THYROID CANCER Thyroid cancer is a malignant tumor that forms in the thyroid gland. Cancer of the thyroid gland is an uncommon cancer, but it is the most common malignancy of the endocrine system. There will be an estimated 56,460 new cases of thyroid cancer and an estimated 1,780 deaths in 2012 (National Cancer Institute at the National Institutes of Health, 2012). There are four types of thyroid cancer: papillary, follicular, medullary, and anaplastic. Papillary and follicular cancers are considered well differentiated. Although the 5-year survival rate for most patients with well-differentiated thyroid cancer is approximately 97%, recurrences occur in approximately 30% of patients (Genzyme Corporation, 2011). Given that most thyroid cancer is diagnosed in relatively young patients (20e50 year olds), routine follow-up and long-term monitoring of these patients are essential. The 20-year survival rate for papillary carcinoma is 95% and a 75% survival rate for follicular carcinoma (Gwyther, 2012). TREATMENT OF THYROID CANCER The treatment pathway for thyroid cancer consists of surgical removal of the thyroid (thyroidectomy), radioiodine remnant ablation followed by a whole-body scan (WBS), life-time hormone replacement, and long-term monitoring. Four to 6 weeks after thyroidectomy, radioactive iodine ablation (RAI) is done to destroy any possible remaining thyroid cells. Thyroid cells are the only cells in the body with the ability to absorb iodine. The radioactive iodine (iodine-131 [I-131]) is given in the form of a pill. Any lingering thyroid cells, cancerous or not, will absorb the toxic iodine and be destroyed. Postoperative RAI remnant ablation is increasingly being used to eliminate the postsurgical thyroid remnant (American Thyroid Association [ATA], 2009). One of the primary goals of RAI according to the ATA (2009) is to facilitate detection of recurrent disease and initial staging. The ATA guidelines also recommend a diet low in iodine 1 to 2 weeks before RAI. This reduces iodine levels in the body and so enables the I-131 to be absorbed more readily by any remaining thyroid cells. A posttherapy WBS is usually performed 2 to 10 days after the RAI is administered (ATA, 2009). The WBS will show any cells that have taken up the RAI and determine if any further treatment is indicated. After thyroidectomy and RAI, patients need to take thyroid replacement hormones for the rest of their lives as every cell in the body relies on them for regulation of metabolism.
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Figure 1. Overview of the thyroid gland (www.houstontx.gov).

(thyroid hormones) gets back to the thermostat, it turns off. As the room cools and hormone levels drop, the thermostat turns back on increasing TSH and the furnace produces more heat (thyroid hormones). Insufcient amounts of TSH will cause hypothyroidism, and overactivity of TSH will cause hyperthyroidism. This is important because as Simmons (2010) states, The

Figure 2. Hypothalamic-pituitary-thyroid axis (www.endocrine. niddk.nih.gov). VOLUME 31 ISSUE 4

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LONG-TERM MONITORING Accurate surveillance for possible recurrence in patients thought to be free of disease is a major goal of long-term follow-up (ATA, 2009). Kloos (2005) states, Patients who appear to be free of disease require a lifetime of follow-up to optimize levothyroxine treatment; and they will undergo periodic stimulation testing because some will still manifest recurrent disease (p. 323). After thyroidectomy, RAI, and initiation of hormone replacement therapy (HRT), routine blood tests are performed for measurement of TSH levels. Any abnormalities in TSH levels will prompt further testing and/or imaging studies. Testing for thyroglobulin (Tg) levels is also done. Tg is a protein produced by thyroid cells, and patients who have had a total thyroidectomy should have very small amounts of Tg in their blood. It should be noted that one abnormal blood test for Tg is not a denite sign of recurrence. Whether Tg levels rise over time is more suggestive of disease. Gwyther (2012) indicates, Thyroid hormone supplements maintain normal thyroid function. A baseline thyroglobulin level O2.0 ng/ml suggests persistent disease and a level below 0.5 ng/ml suggests absence of disease. Subsequent levels that rise with time strongly suggest recurrent disease (p. 34). Patients with elevated Tg levels, neck ultrasounds negative for nodules, and negative I-131 WBS can undergo Thyrogen stimulation test. This is performed in conjunction with a nuclear medicine studyda PET-CT scan. This study evaluates for the recurrence of thyroid cancer and is performed in an outpatient setting over a period of 5 days. The main role of PET-CT is to detect local recurrence when the patient has a raised Tg level but a negative neck ultrasound or negative 131I WBS (Gwyther, 2012, p. 35). PET-CT imaging has an important role in location of disease and provides prognostic information related to the patients survival (Kloos, 2008). To improve the sensitivity of the Thyrogen scan, the test must be able to detect even small amounts of thyroid cells. TSH must be at high levels in the bloodstream. With TSH in the bloodstream, any thyroid cells in the body will be stimulated to absorb radioactivity. Thyrogen stimulated PET-CT scans require the use of radioactive glucose. Because thyroid cancer cells have a faster metabolism than normal cells, they will take up glucose at a rapid rate. The radioactivity is then seen with the use of special scanning equipment and is used to form an image of any tumors in the body. PET-CT plays an important role in the detection of metastatic disease in well-differentiated thyroid cancer and has the advantage of imaging the whole body so that distant metastases may be detected (Gwyther, 2012).
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There are currently two options available for increasing TSH in the bloodstream before a Thyrogen stimulated PET-CT scan. The rst is to discontinue taking thyroid replacement hormones for 4 to 6 weeks prior which can induce hypothyroidism. The second option is to receive Thyrogen (recombinant human thyrotropin rhTSH Thyrogen Genzyme Corporation, Cambridge, MA) injections. Thyrogen injections allow patients to remain on HRT and avoid the sometimes debilitating symptoms of hypothyroidism and therefore improve the patients quality of life. Symptoms of hypothyroidism can include cold intolerance, dry coarse skin, weight gain with poor appetite, fatigue, slow thinking, hypersomnia and constipation (Simmons, 2010, p. 24). Thyrogen for injection is a version of TSH manufactured by biotechnology that is similar to the TSH that is naturally produced in the body. Thyrogen was initially approved by the Federal Drug Administration in 1998 for use as a diagnostic tool in patients being tested for the recurrence of well-differentiated thyroid cancer who had a thyroidectomy. Emmanouilidis et al. (2009) notes, Before genetically engineered recombinant human TSH (rhTSH) was available, the only way to generate an elevated endogenous TSH was by thyroid hormone abstinence for a period of about 4 weeks after surgery. During this time, patients had to endure the debility and fatigue of a slowly developing hypothyroidism as well as socioeconomic side effects (p. 763). The main advantage of Thyrogen is the avoidance of the debilitating symptoms of hypothyroidism while allowing effective treatment of thyroid cancer (Duntas, Tsakalakos, Grab-Duntas, Kalarritou, & Papaddodima, 2003). NURSING IMPLICATIONS Undergoing a test for the recurrence of cancer can evoke strong emotions from the patient. As indicated by Vijayakumar, Briscoe & Vijayakumar (2007), volume 3 (issue 2), Nurses with experience in oncological problems can better explain the new technological advancements in the diagnosis and treatment of patients including PET scanning and radioimmunotherapy and help patients to make the proper decisions. THE PROCEDURE FOR A THYROGEN SCAN The procedure for a Thyrogen stimulated PET-CT scan is explained here (Table 1). One Day 1 of the Thyrogen scan schedule before the rst Thyrogen injection, the nurse assesses the patient for knowledge of the procedure. The nurse gives information and answers questions and concerns the patient may have. The patient is informed of the need for compliance in coming daily for this study. Any issues involving transportation to the facility should be addressed at this time.
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Table 1. Procedure for a Thyrogen stimulated PET-CT scan

Treatment Day Day 1 Day 2 Day 3 Day 4 Day 5 Procedure Patient assessment and education, blood draw for thyroid hormone levels, rst Thyrogen injection Second Thyrogen injection Blood draw for thyroid hormone levels, Thyrogen stimulated PET-CT scan performed OFF Blood draw, discharge, and follow-up instructions

On Day 5, the patient has blood drawn for serum Tg and TSH levels. Assessment of how the patient experienced the procedure and reinforcement of follow-up with their physician is provided. CONCLUSION Although this multiday procedure is performed in an outpatient setting where the environment is somewhat more relaxed than an inpatient setting, the patient undergoing this study may be far from relaxed. Just the thought of a recurrence of cancer can elicit strong emotions. Radiology nurses play an important role as patient advocates and coordinators of the health care team. Nurses often identify questions and struggles these patients may be going through as they attempt to understand diagnosis and other issues. Radiology nurses need to reach out in a compassionate way to patients to create a relationship to ensure quality of care and a safe journey through the procedure.

The patient is prepared for the rst Thyrogen injection. Thyrogen is reconstituted with 1.2 mL of sterile water for injection. After reconstitution, a 1 mL (0.9 mg of Thyrogen) solution is administered by intramuscular injection into the muscle of the buttock (Genzyme Corporation, 2011). The patient is instructed regarding side effects, which can include nausea, headache, vomiting, and dizziness (Genzyme Corporation, 2011). Patients should also be instructed to report any hypersensitivity reactions, such as rash, pruritus, ushing, or respiratory difculties. On Day 2 before the second injection, the nurse will assess for any side effects related to the rst injection and educate the patient regarding preparation for the PET-CT scan on Day 3. These instructions include the need for the patient to follow a low-carbohydrate diet 24 hr before the scan to prepare for the uptake of radioactive glucose for the PET-CT scan and the need to be nothing by mouth (NPO) except for water 6 hr before the scan. Special instructions for patients with diabetes are reviewed regarding the withholding of diabetic medications 6 hr before the scan, and the need for nger stick testing of glucose is discussed. Explanation of the need for the patient to have insertion of an intravenous (IV) line before the scan is given. Vijayakumar et al. (2007), volume 3 (issue 2) found that Some diabetic patients who were fasting for the nuclear medicine procedures experienced hypoglycemia and needed immediate nursing help to check the blood sugar level and correct it. On Day 3, the patient has the Thyrogen PET-CT scan. It is important to assess the patients neurological status before the scan especially if the patient is a diabetic. The patient has a ngerstick, and the nurse assesses the blood sugar level before the scan. Any signs of hyperglycemia or hypoglycemia must be addressed at this time. NPO status is also assessed and if the patient has been compliant with their instructions and the scan can proceed, an IV line is inserted for the administration of the radioactive glucose tracer. Blood is drawn for serum Tg and TSH levels. The nurse should assess the patient for any untoward response after the tracer is given to the patient (Vijayakumar et al., 2007). The patient is reminded that Day 4 of this study is a day off, and they must return on Day 5 for a blood draw.
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