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Recommendation 59
A. Radioactive iodine resistant (RAIR) DTC (including OTC) cannot be
diagnosed in patients who have not received an ablative or treatment
dose of RAI. Patients who meet criteria for RAI should receive
ablative or treatment administrations of RAI to determine status.
(GPS)
B. Patients who have RAIR DTC should not receive additional empiric
RAI therapy. Other treatments should be considered. (GPS)
Recommendation 60
A. Patients with RAIR metastatic DTC that is asymptomatic, stable or
minimally progressive, or who have clinically significant co-morbidities
can be monitored on TSH-suppressive thyroid hormone therapy with
serial radiographic imaging every 3–12 months. (C-L)
B. In the absence of planned systemic treatment or redifferentiation
therapy, molecular testing is not routinely recommended in patients
with RAIR residual DTC. (C-M)
Recommendation 61
➤ Tissue-based biomarker testing to identify actionable oncogenic
driver alterations in RAIR DTC should be performed prior to initiating
systemic therapy for progressive disease. (S-M)
Recommendation 62
➤ For patients with progressive RAIR DTC without an actionable biomarker-
linked FDA-approved first-line therapy, multikinase inhibitor (MKI)
therapy with either lenvatinib or sorafenib is recommended. In most
cases, lenvatinib is the preferred first-line MKI. (S-H)
Recommendation 63
A. Lenvatinib or other therapy should be initiated without delay in
patients with symptomatic RAIR DTC for whom local therapy, such as
radiation or surgery, is not appropriate. (S-M)
B. For patients with asymptomatic RAIR DTC that has progressed
over the prior 12–14 months and local therapy is not appropriate,
if efficacy outcomes are the most important goal of treatment,
earlier initiation of lenvatinib may be considered. For patients with
asymptomatic progressive RAIR DTC for whom quality of life is a
major priority, delaying the initiation of lenvatinib and continuing
disease monitoring may be most appropriate. (GPS)
