Radioiodine Ablation and Treatment
For Papillary and Follicular Thyroid Cancer
(By Douglas Van Nostrand, M.D. Reprinted, with permission, from pages 161-163, 177, and 194 of Chapters 17 and 18 of the book “Thyroid Cancer: A Guide for Patients”, (Keystone Press, 2004. Douglas Van Nostrand, M.D., Gary Bloom, and Leonard Wartofsky, M.D. )
What is radioiodine ablation?
Radioiodine ablation is radiation therapy in which radioactive iodine is administered to destroy or ablate residual healthy thyroid tissue remaining after thyroidectomy.
What is radioiodine treatment?
Radioiodine treatment is radiation therapy in which radioactive iodine is administered to destroy or ablate thyroid cancer by irradiating that tissue.
What is the difference between ablation and treatment?
Many physicians use “ablation” and “treatment” interchangeably. Other physicians use “ablation” to mean the administration of radioiodine to eliminate any normal thyroid tissue remaining in the neck after initial surgery and “treatment” to mean the subsequent administration of radioiodine for the elimination of metastatic disease in the neck or elsewhere.
Why do I have any thyroid tissue left after my surgery? I thought my surgeon took it all out.
Although your surgeon removed your thyroid gland, most surgeons leave behind small amounts of thyroid tissue to minimize any damage to the nerve that controls your voice box. This nerve is called the recurrent laryngeal nerve and runs behind your thyroid tissue. Your surgeon may also leave some thyroid tissue behind to make sure some of your parathyroid glands remain intact. These glands control your body’s calcium levels and are usually located within or behind your thyroid tissue.
Why do I need an initial radioiodine ablation when my physician believes he has removed all of my thyroid carcinoma?
Most physicians will recommend that patients with thyroid carcinoma undergo at least one ablation radiation therapy with radioiodine. Research and fifty years of experience suggest that the combination of surgery, radioiodine ablation, and thyroid hormone replacement can reduce the chances of your thyroid carcinoma recurring. There are some situations, however, in which your physicians may not recommend an initial ablation with radioiodine.
What are the criteria for not receiving an ablation with radioiodine?
Radioiodine ablation may not be recommended depending on several factors. These include the size of the original thyroid cancer, the number of sites involved, the lack of any involvement of the borders of the thyroid or adjacent tissues, and a lack of evidence that the cancer has spread…
If radioiodine ablation is recommended, what are its goals?
Radioiodine ablation has four goals:
First, and for most patients it will reduce the chance of the thyroid cancer recurring….
Second, destroying the remaining thyroid tissue will improve the ability of the radioiodine whole body scan to monitor you for evidence of any recurrence of the cancer…
The third goal is to facilitate the use of the blood levels of thyroglobulin to monitor you for metastasis. Normal thyroid tissue also produces thyroglobulin, and thus, in the presence of normal thyroid tissue, changes in your blood thyroglobulin levels are not as reliable for indicating spread of your cancer….
The fourth goal is to enhance the effectiveness of future radioiodine treatments, if needed…
Side Effects of Radioiodine
- Potential side effects will vary depending on the dosage of the radioiodine administered.
- In regard to selecting dosages for radioiodine ablation or treatment, three points should be remembered. First, the type, frequency, and severity of side effects must be weighed against the benefit of the dosage for ablation or treatment. Second, although your physicians may know the potential risks and benefits of the various dosages, they cannot predict what will happen in a given patient. Everyone responds differently to radioiodine ablation or treatment, which often makes it difficult for a patient to decide which dosages might be best for him or her. Your personal physician is likely your best resource to help you make this decision…
- [Some examples of potential side effects include nausea and vomiting, dry mouth, change in taste (in as many as a third of patients, typically lasting several weeks), salivary gland swelling and pain, and drop in blood counts, and others.]
- As a general rule, side effects increase in frequency and severity with repeated or larger doses of radioiodine.
- We do not believe that any strict upper limit of total cumulative dosage … should be used. We believe that many factors must be weighed including but not limited to (1) the severity of the disease, (2) the location of the disease, (3) whether the metastasis takes up radioiodine, (4) how the patient has previously responded to radioiodine, (5) how long ago the last treatment was administered, (6) the total blood counts (7) what was the response of the blood counts to the last radioiodine treatment, (8) the age of the patient, (9) the patient’s other health problems, if any, and (10) other options available to the patient.
- [Regarding side effects] keep in mind three things:
- Many of these side effects are infrequent
- Most of the side effects are manageable.
- The risk of the frequency and severity of the side effects must be weighed in light of the severity of your thyroid cancer
Signs to Watch for in Case of Drug Reaction (Allergy)
- Shortness of breath
- Chills/Rigors
- Fever
- Rash/Hives
What about when I go home from the hospital?
- Minimize contact (less than 3 feet or 0.6 meter for more than 1 hour each day) with everyone for the first five days, and with small children or pregnant women for eight days.
- Do not sit next to someone in an automobile for more than one hour.
- Sleep in a separate room and use separate bath linen and launder these and underclothing separately for one week.
- Wash your hands with soap and plenty of water every time you use the toilet.
- Rinse the sink and tub thoroughly after using them.
- Use separate eating utensils or disposable eating utensils. Wash eating utensils separately for one week. Do not prepare food for others.
- Flush toilet 2-3 times after use for two weeks after discharge.
- Males should sit when urinating to avoid splashing for one week.
- Discuss with your doctor how long you should wait before starting a pregnancy after your treatment (usually at least two months for males and six months for females).
- If you are breastfeeding, it should be discontinued, but can be resumed for subsequent childbirths.
Last updated: Oct. 2008
After receiving RAI
Your Home Stay or Hospital/Stay
After receiving RAI for a diagnostic scan only, you will go home immediately. After your RAI treatment dose, you may be sent home immediately, or you may stay in the hospital for one or more days.
The size of the treatment dose that involves a hospital stay varies from one jurisdiction to another, and sometimes from one hospital to another in the same jurisdiction so make sure you check with your hospital or doctor.
Currently, patients go home immediately after larger doses of RAI than in the past. Your home circumstances, such as whether there is an infant at home, may affect the decision about going home or staying in the hospital for a day or more after your treatment dose.
Below are samples of guidelines from informational booklets and materials we studied for Stevie JoEllie's post treatment care. Please note that your physician and hospital may have different procedures and guidelines.
Information If You Go Home Immediately After Receiving RAI
As your doctor will have explained to you, you will be receiving radioactive iodine as your treatment. Radioactive iodine decreases the function of thyroid cells and inhibits their ability to grow. It is given to you in liquid or pill form and goes directly to the thyroid gland where it is absorbed by the thyroid tissue.
Most of the radioactive iodine will be received by your thyroid gland. Any radioactive iodine not collected by the thyroid gland will be eliminated during the first few days through urine, feces, saliva and sweat.
The following steps listed below will help assure that the excreted radiation from your body does not contaminate the environment or cause harm to other people.
For information about possible side effects of radioactive iodine, see the information below in the section about the hospital stay.
What do I do at home?
If you go home immediately after a treatment dose, use the following guidelines regarding distance, time, and hygiene.
- Minimize contact (less than 3 feet or 0.6 meter for more than 1 hour each day) with everyone for the first five days, and with small children or pregnant women for eight days.
- Do not sit next to someone in an automobile for more than one hour.
- Sleep in a separate room and use separate bath linen and launder these and underclothing separately for one week.
- Wash your hands with soap and plenty of water every time you use the toilet.
- Rinse the sink and tub thoroughly after using them.
- Use separate eating utensils or disposable eating utensils. Wash eating utensils separately for one week. Do not prepare food for others.
- Flush toilet 2-3 times after use for two weeks after discharge.
- Males should sit when urinating to avoid splashing for one week.
- Discuss with your doctor how long you should wait before starting a pregnancy after your treatment (usually at least two months for males and six months for females).
- If you are breastfeeding, it should be discontinued, but can be resumed for subsequent childbirths.
Information During Your Hospital Stay
As your doctor will have explained to you, you will be receiving radioactive iodine as your treatment. Radioactive iodine decreases the function of thyroid cells and inhibits their ability to grow. It is given to you in liquid or pill form and goes directly to the thyroid gland where it is absorbed by the thyroid tissue.
Most of the radioactive iodine will be received by your thyroid gland. Any radioactive iodine not collected by the thyroid gland will be eliminated during the first two days through urine, feces, saliva and sweat.
How Long Will I Be in Isolation in the Hospital?
After the doctor has given you your treatment you are requested to remain in your room with the door closed until you are released from isolation by the radiation safety officer. This is usually one or more days after you have taken the medication.
This can be a great time to get caught up on things such as reading magazines or talking to friends and family on the telephone. Please remember to bring diversional activities with you to the hospital. There is a TV available.
You may bring your glasses, but do not bring items such as a laptop computer, which may become contaminated and have to stay in the hospital.
What about Visitors?
It is strongly advised that there be no visitors for the first 24 hours following radiation. We encourage you to use the telephone to communicate with your friends and family. If you receive visitors, a maximum visit of 30 minutes is allowed only.
Visitors must wear gloves, protective shoe covers and a gown before entering the room. The amount of space between your visitor and you must be a maximum. This means your visitor must sit at the entrance of the door with you at the other end of the room.
At the end of the visit, your visitor must dispose the gloves and shoe covers in the garbage located in the room and place the gown in the hamper. Visitors may not use your washroom or eat or drink any of your food.
Pregnant women and children under the age of 18 may not visit during your hospital stay.
How Should I Communicate with my Nurse?
Although your nurse will spend very little time in your room, you can communicate frequently with your nurse by using the telephone and/or the intercom. Your nurse will also check in with you frequently by telephone or intercom to assess how you are doing.
What Should I Wear in the Hospital?
Please wear a hospital gown during your hospital stay and hospital slippers to avoid any contamination of your own clothes by perspiration. Your mattress and pillow will becovered with plastic. Please do not remove these coverings during your hospital stay.
What about Cleaning my Room?
You will be asked to make your own bed, if necessary. Dispose all linen and garbage in plastic bags provided in your room. All cutlery and dishes are to be disposed in a plastic bag also. Rinsing the sink, faucets and tub after use will help keep the radiation contamination to a minimum.
How do I Order my Meals?
You will remain on the low iodine diet. There are no choices. You may order kosher, vegetarian, or diabetic diets.
What about my Medications. Can I still take them?
If you are on medication, please let your doctor know. If your doctor decides that you may continue to take your medication during your hospital stay, please bring enough with you for the duration of your stay. You may store the medication in your room and take when required.
Is there Anything Else I should Know?
Please flush the toilet two or three times after elimination and wash your hands. Remember the urine is one of the key systems that excretes the excess radiation.
"Just for the Men"- Please sit to void (pass water) to prevent any splashing contamination of the surrounding area.
Showering two or three times a day and washing your hair will help remove the excreted radiation through perspiration. Extra towels will be provided for you. When getting out of the shower, make sure you have a towel on the floor to step on.
Sucking on sour candies for the first 24-48 hours after radioiodine therapy is recommended by some thyroid cancer specialists to help reduce excessive radiation to your salivary glands. They recommend taking candies every 15 minutes during the day, as well as several times at night.
Further information: A study conducted in Japan and published in early 2005 compared two different timings of starting lemon candy. One group of patients started candy an hour after the radioiodine. The other group waited 24 hours before starting the candy. Both groups were asked to take 1-2 candies every 2-3 hours during the daytime through the 5th day after the radioiodine.
The group that waited 24 hours had fewer salivary side effects. The authors concluded that waiting for 24 hours was preferable. However, they also noted that the study had limitations. Among these were that it was not double blinded, was not controlled, and patients in the group waiting 24 hours “tended to be treated more intensively” for salivary side effects. (Nakada, K, et al. Journal of Nuclear Medicine, 46(2): 261-6, 2005).
Several Thyroid Cancer Survivors Association medical advisors sent comments about this study. They noted that it is a single study and that it needs verification, because it was “non-controlled and not randomized adequately.”
Some recommended conducting a study that is randomized, that includes a no-treatment control group that takes no candy at all, and that measures both acute and chronic symptoms as well as radioiodine uptake and retention in the salivary glands.
The American Thyroid Association’s guidelines published in early 2006 said that “evidence is insufficient to recommend for or against” taking sour candy, or other approaches such as amifostine, drinking a lot of water, or using cholinergic agents, however I would like to point out that sucking on "sour patch candy" dit help Stevie JoEllie feel better.
