Authors and Disclosures

Fabián Pitoia, MD,1 Veronica Ilera, MD,

2 Maria B. Zanchetta, MD,

1 Adriana

Foffano, MD,1 and Hugo Niepomniszcze, MD, PhD

1

1Division of Endocrinology, Hospital de Clinicas, University of Buenos Aires, Buenos

Aires, Argentina 2Division of Endocrinology, Hospital Aleman, Buenos Aires, Argentina.

Disclosure: Fabián Pitoia is an external medical advisor for Genzyme Corporation.

From Endocrine Practice

Optimum Recombinant Human

Thyrotropin Dose in Patients With

Differentiated Thyroid Carcinoma and

End-stage Renal Disease

Fabián Pitoia, MD; Veronica Ilera, MD; Maria B. Zanchetta, MD; Adriana Foffano,

MD; Hugo Niepomniszcze, MD, PhD

Posted: 02/10/2009; Endocrine Practice. 2008;14(8):961-966. © 2008 American

Association of Clinical Endocrinologists

Abstract and Introduction

Abstract

Objective: To evaluate serum thyrotropin (TSH) concentrations after conventional (0.9

mg) or half-dose (0.45 mg) administration of recombinant human TSH (rhTSH)

injections intramuscularly in patients with end-stage renal disease and differentiated

thyroid cancer.

Methods: In this case series, we administered 2 doses of 0.9-mg rhTSH or 2 doses of

0.45-mg rhTSH to 3 patients with renal failure and differentiated thyroid cancer who

were receiving hemodialysis. Basal serum TSH concentrations were assessed while the

patients were taking thyroid hormone therapy. Serum TSH was measured on days 2, 3,

5, 8, 10, 14, and 17 of the study. Thyroglobulin and thyroglobulin antibodies were also

measured on days 5 and 7. Patients were asked to report any adverse effects.

Results: Patient 1, who received 2 injections of 0.9-mg rhTSH administered on days 1

and 3, had persistently elevated serum TSH levels for approximately 11 days. Peak

serum TSH measured on day 5 was 644 mIU/L. Self-limited diarrhea was the only

reported adverse effect. Patients 2 and 3 received 0.45 mg of rhTSH on 2 consecutive

days (days 1 and 2), and both exhibited persistently elevated serum TSH levels for 12

days. The peak serum TSH values on day 3 were 402 mIU/L in Patient 2 and 386

mIU/L in Patient 3. No adverse events were observed in these 2 patients. Patient 2

received thyrotropin alfa for injection to confirm disease status. Patient 3 also received a

radioiodine dose because of presumed persistent disease.

Conclusion: High serum TSH levels achieved after conventional and half-dose

administration of rhTSH suggest that a dose adjustment might be considered in patients

with end-stage renal disease. (Endocr Pract. 2008;14:961-966)

Introduction

Differentiated thyroid cancer has an excellent prognosis in most patients after the initial

treatment. The usual treatment approach involves total thyroidectomy, often followed

by radioiodine ablation of the thyroid remnant.[1]

Adequate uptake of radioiodine by remnant or remaining malignant thyroid tissue is

dependent on an elevated level of thyrotropin (TSH) in the blood. In the past, it was

necessary to withdraw thyroid hormone-suppressive therapy for several weeks to cause

TSH elevation, and a somewhat arbitrary target level of greater than 25 mIU/L was

used.[2,3]

Children may have sufficiently elevated TSH concentrations after shorter

periods of withdrawal.[4]

Levothyroxine withdrawal is nearly always associated with signs and symptoms of

hypothyroidism, which are generally not well tolerated.[5,6]

The hypothyroid state

usually impairs the quality of life of patients with thyroid cancer, reduces productivity,

and can also promote thyroid tumor growth and worsen comorbid diseases.[7] Moreover,

patients asked to undergo repeated hypothyroid periods have documented lower

compliance with followup.[8]

The human gene that encodes the TSH β subunit was identified in 1988,[9] and methods

were established to synthesize the dimeric form of recombinant human TSH (rhTSH) in

vitro soon thereafter.[10] The rhTSH produced the same effects in in vitro assays as did

natural human TSH[11] and was soon shown to be active in healthy volunteers.

[12,13]

Extensive clinical studies followed. Between 1997 and 2007, more than 40 centers

around the world studied patients with differentiated thyroid cancer who received

rhTSH as a part of their evaluation or treatment.[14-16]

Despite the extensive experience using rhTSH, there are seldom reports of its use in

patients with renal failure.[17-19]

In such patients, the quality of life is, per se, affected by

several circumstances including the frequency of hemodialysis and higher frequencies

of infections, etc, and thyroid hormone withdrawal may aggravate this situation.

Recombinant human TSH would seem to be a good alternative in patients with renal

disease, but because of the extensive renal clearance of rhTSH, the proper dosage has

never been firmly established.

In this case series, we present the results observed in 3 patients with end-stage renal

disease and thyroid cancer who were receiving hemodialysis 3 times per week. In 1

patient, we used 2 injections of 0.9-mg rhTSH, and in the other 2 patients, we

administered 2 injections of 0.45-mg rhTSH.

Patients and Methods

Patient 1

A 46-year-old woman with a body mass index of 26 kg/m2 underwent partial

parathyroidectomy because of tertiary hyperparathyroidism 7 years earlier. During

surgery, a multinodular goiter was discovered. Total thyroidectomy was performed, and

pathologic examination revealed a 0.7-cm papillary thyroid carcinoma. A suspicious

jugular lymph node was also intrasurgically analyzed, and findings revealed the

presence of neoplastic thyroid cells. A modified neck dissection (levels II-III-IV and

VI) was then performed. The pathologic results showed the presence of metastases in 12

of 40 removed lymph nodes. Remnant ablation was performed with 100 mCi of iodine I

131 (131I) after thyroid hormone withdrawal. The hypothyroid state was poorly

tolerated, and the patient refused thyroxine withdrawal for several years thereafter, thus

impairing her follow-up evaluations.

A persistently detectable thyroglobulin concentration (between 1.2 and 1.9 ng/mL)

while the patient was taking thyroid hormone-suppressive therapy (with normal findings

from neck ultrasonography examinations) led us to offer injections of rhTSH followed

by therapeutic high activity 131I. A 0.9-mg dose of rhTSH was injected intramuscularly

on days 1 and 3.

Patient 2

A 59-year-old woman with a body mass index of 28 kg/m2 and a history of bilateral

nephrectomy underwent a partial parathyroidectomy. The discovery of a thyroid nodule

led to a surgical biopsy, the findings of which showed papillary thyroid cancer. Total

thyroidectomy was performed. Pathologic examination showed a multicentric and

bilateral papillary microcarcinoma. Thyroxine was withdrawn, and ablation of the

thyroid remnant was accomplished using 70 mCi 131I.

A follow-up evaluation of stimulated thyroglobulin/thyroglobulin antibody

measurement was proposed 1 year later. In view of the results of the first case, we

decided to use a lower rhTSH dose (2 consecutive 0.45-mg injections on days 1 and 2).

Patient 3

A 40-year-old man with chronic renal failure and a body mass index of 23 kg/m2 had a

partial parathyroidectomy 3 years earlier. A thyroid micronodule was discovered during

surgery, and the intrasurgical analysis showed the presence of papillary thyroid cancer.

Total thyroidectomy was performed, and a 0.7-cm papillary microcarcinoma with

capsule invasion was found in the right thyroid lobe. No affected lymph nodes were

found after the analysis of 16 operated nodes. Levothyroxine was withdrawn, and

remnant ablation using 100 mCi 131I was performed 1 month later, but the hypothyroid

symptoms were poorly tolerated.

A persistently detectable thyroglobulin concentration of 1.51 ng/mL while on thyroid

hormone-suppressive therapy (with normal findings from neck ultrasonography

examinations) led us to administer 60 mCi 131I after 0.45-mg rhTSH injections on 2

consecutive days.

Protocol

TSH concentrations were measured using an immunometric assay in solid phase with a

functional sensitivity of 0.03 µIU/mL. Thyroglobulin concentrations were measured by

immunochemiluminometric assay (IMMULITE, Diagnostics Products Corporation, Los

Angeles, California). Thyroglobulin antibodies were measured by radioimmunoassay

(RSR Limited, Pentwyn, Cardiff, United Kingdom) with a detection limit lower than 0.5

IU/mL.

The clinical protocol used in Patient 1 was as follows:

Measurement of basal serum TSH concentration while taking thyroid hormone therapy

Day 1: Hemodialysis followed by intramuscular injection of 0.9-mg rhTSH

(thyrotropin alfa for injection [Thyrogen], Genzyme Pharmaceuticals,

Cambridge, Massachusetts)

Day 2: Serum TSH measurement

Day 3: Hemodialysis followed by a second intramuscular injection of 0.9 mg of

rhTSH

Day 4: Administration of 100 mCi 131I

Day 5: Measurement of serum TSH, thyroglobulin, and thyroglobulin antibodies

followed by hemodialysis

Day 7: Serum thyroglobulin and thyroglobulin antibody measurement

Day 8

and 10:

Hemodialysis followed by serum TSH measurement

Day 11: Post-dose whole body scan

Day 12: Hemodialysis

Day 14: Serum TSH measurement

Day 15: Hemodialysis

Day 17: Hemodialysis followed by serum TSH measurement

The protocol for Patients 2 and 3 was identical to the protocol for Patient 1 except that

rhTSH was administered on 2 consecutive days (days 1 and 2), and the injected dose

was 0.45 mg (half ampoule) on each day. Patient 2 received thyrotropin alfa for

injection (Thyrogen) to confirm disease status. Patient 3 also received a radioiodine

dose because of presumed persistent disease. The timing of TSH measurements was

identical in the 3 patients and is shown in Table 1 .

[ CLOSE WINDOW ]

Table 1. Serum Thyrotropin (TSH) Concentrations in 3 Patients With

Differentiated Thyroid Cancer and End-stage Renal Disease After Administration

of Recombinant Human TSH

TSH, mIU/L

Patient Basal Day 2 Day 3 Day 5 Day 8 Day 10 Day 14 Day 17

1a 0.8 456 521 644 175 49 12 2.4

2b 0.23 261 402 210 47 22 12 4

3b 0.03 276 386 203 51 19 9 1.9

a Patient 1 received 2 injections of 0.9-mg recombinant human TSH (injections given on

days 1 and 3). b Patients 2 and 3 received 2 injections of 0.45-mg recombinant human TSH (injections

given on days 1 and 2).

All 3 patients gave written voluntary consent to receive rhTSH. Patients 1 and 3

received explanation about the offlabel use of a therapeutic radioiodine dose after 2

injections of 0.9-mg rhTSH, and Patients 2 and 3 were provided explanations about the

empiric choice of a lower rhTSH dose to achieve similar serum TSH levels as observed

in patients with normal renal function. Procedures were applied in agreement with the

ethical guidelines of our institution.

Results

Patient 1

TSH measurements are shown in Table 1 and in Figure 1. The serum TSH level on day

5 was 644 mIU/L, and it remained elevated for at least 11 days. The serum

thyroglobulin concentration measured 48 hours after the second rhTSH injection was

0.9 ng/mL. In the same sample, thyroglobulin antibodies were undetectable. On day 7,

the thyroglobulin concentration was 1.2 ng/mL, and thyroglobulin antibodies were

again undetectable. On day 11, a whole body scan showed only a faint thyroid bed

uptake (2%). Self-limited diarrhea was observed 48 hours after the first rhTSH

injection.

Table 1. Serum Thyrotropin (TSH) Concentrations in 3 Patients With

Differentiated Thyroid Cancer and End-stage Renal Disease After Administration

of Recombinant Human TSH

TSH, mIU/L

Patient Basal Day 2 Day 3 Day 5 Day 8 Day 10 Day 14 Day 17

1a 0.8 456 521 644 175 49 12 2.4

2b 0.23 261 402 210 47 22 12 4

3b 0.03 276 386 203 51 19 9 1.9

a Patient 1 received 2 injections of 0.9-mg recombinant human TSH (injections given on

days 1 and 3).

b Patients 2 and 3 received 2 injections of 0.45-mg recombinant human TSH (injections

given on days 1 and 2).

Figure 1. Serum thyrotropin (TSH) levels after the administration of recombinant

human TSH (rhTSH) in 3 patients with differentiated thyroid cancer and endstage renal

disease. Patient 1 received 2 injections of 0.9-mg rhTSH (given on days 1 and 3).

Patients 2 and 3 received 2 injections of 0.45-mg rhTSH (given on days 1 and 2).

The patient was considered free of disease, and after 3 years of follow-up, she continues

to have undetectable thyroglobulin levels with undetectable thyroglobulin antibodies

and normal neck ultrasonography findings while taking thyroid hormone-suppressive

therapy.

Patient 2

The serum thyroglobulin level assayed 72 hours after the second 0.45-mg rhTSH

injection was undetectable (<0.2 ng/mL), as were thyroglobulin antibodies. The serum

TSH concentration peaked at 402 mIU/L on day 3 ( Table 1 and Fig. 1). No adverse

events occurred.

Table 1. Serum Thyrotropin (TSH) Concentrations in 3 Patients With

Differentiated Thyroid Cancer and End-stage Renal Disease After Administration

of Recombinant Human TSH

TSH, mIU/L

Patient Basal Day 2 Day 3 Day 5 Day 8 Day 10 Day 14 Day 17

1a 0.8 456 521 644 175 49 12 2.4

2b 0.23 261 402 210

47 22 12 4 3b 0.03 276 386 203 51 19 9 1.9 a Patient 1 received 2 injections of 0.9-mg recombinant human TSH (injections given on days 1 and 3). b Patients 2 and 3 received 2 injections of 0.45-mg recombinant human TSH (injections given on days 1 and 2). As a low-risk patient, she was considered free of disease after an undetectable stimulated thyroglobulin level associated with normal neck ultrasonography findings. Patient 3 The serum thyroglobulin level measured 72 hours after the last 0.45-mg rhTSH injection was 4.1 ng/mL, while thyroglobulin antibodies were undetectable. The peak serum TSH concentration was 386 mIU/L on day 3 ( Table 1 and Fig. 1). No adverse events occurred. Table 1. Serum Thyrotropin (TSH) Concentrations in 3 Patients With Differentiated Thyroid Cancer and End-stage Renal Disease After Administration of Recombinant Human TSH TSH, mIU/L Patient Basal Day 2 Day 3 Day 5 Day 8 Day 10 Day 14 Day 17 1a 0.8 456 521 644 175 49 12 2.4 2b 0.23 261 402 210 47 22 12 4 3b 0.03 276 386 203 51 19 9 1.9

a Patient 1 received 2 injections of 0.9-mg recombinant human TSH (injections given on

days 1 and 3). b Patients 2 and 3 received 2 injections of 0.45-mg recombinant human TSH (injections

given on days 1 and 2).

Although this patient had a normal post-dose whole body scan and normal neck

ultrasonography findings, he probably had persistent or recurrent disease as

demonstrated by the continued elevation of the thyroglobulin concentration while taking

levothyroxine treatment and after the use of rhTSH.

Discussion

End-stage renal disease usually affects thyroid function. These alterations include: (a)

lower levels of thyroid peripheral serum hormones, (b) decrease in triiodothyronine and

thyroxine binding to transporting proteins, (c) increase in the storage of organic iodine

in the thyroid gland, (d) elevation of basal serum TSH levels, (e) decrease in the

response of TSH to TSH-releasing hormone, and (f) alteration in serum TSH

glycosylation, among others.[20-22]

Thyroid cancer incidence is reportedly high in patients with renal failure. A weakened

immune system, secondary hyperparathyroidism, nutritional deficiencies, and altered

DNA repair have been proposed as mechanisms.[22-25]

However, the incidence of

differentiated thyroid cancer is not increased in patients with renal failure who are

treated with hemodialysis and have surgery performed because of the presence of

hyperparathyroidism.[26,27]

It has recently been shown that compared with the general

population, the incidence of differentiated thyroid cancer in transplanted patients with

renal failure is higher, and there is also a higher prevalence of lymph node metastasis at

the time of diagnosis.[28]

One of the biggest challenges in patients receiving hemodialysis is the use of high

radioiodine activities due to the altered and variable clearance rates of iodine from the

blood, secondary to variations in dialysis protocols that complicate the selection of

appropriate 131I activity. However, there is compelling evidence that

131I is

hemodialysed, and there have been isolated case reports showing that the careful

handling of the hemodialysis material after radioiodine administration may be safe for

patients and health care professionals involved in the treatment.[22,27]

Recently, Holst et

al[29] performed an extensive literature review regarding this topic. In this review, the

authors identify 20 case reports of radioiodine treatment in patients with end-stage renal

disease.

Although many of these authors do not give specific recommendations about the 131I

activity reductions,[29-31]

others clearly suggest that the amount of 131I should be

decreased.[32,33]

In these articles, a reduction of 40%[32] or use of 25% of the empiric

radioiodine otherwise considered in patients without renal disease[33]

has been

recommended if the patient is on a regimen of hemodialysis sessions 3 times a week.

Dosimetry might be a more suitable method to calculate the required activity in these

cases.[29,30]

In Patients 1 and 3, we administered the empiric radioiodine dose reduced by

approximately 40%.

Patients with renal failure usually have a low quality of life that makes it hard to accept

withdrawal of thyroid hormone-suppressive therapy to perform the follow-up of

differentiated thyroid cancer. Recombinant human TSH is currently approved by the US

Food and Drug Administration and the European Medicines Agency to be used for

diagnostic purposes,[34] and it was recently also approved for thyroid remnant ablation

by both organizations.[35] The rhTSH-aided radioiodine treatment has been presented in

many isolated reports and has recently been reviewed.[14,16]

We have also shown the

usefulness of this procedure for the ablation of thyroid remnants and for the treatment of

patients with metastatic thyroid cancer.[15]

In our experience with patients with normal renal function, the mean serum TSH level

after administration of 2 consecutive 0.9-mg rhTSH injections—measured 24 hours

after the last injection—was 117 ± 34 mIU/L (range, 90-178 mIU/L),[15] which is

similar to serum levels seen by others.[34]

In Patient 1, we decided to administer 2 doses of 0.9-mg rhTSH. Because of technical

reasons, we had to administer the 2 rhTSH injections 48 hours apart. Although the

laboratory result showed a high serum TSH concentration after the first injection, this

TSH value was not available until 3 days later. The detectable thyroglobulin level while

Patient 1 was taking thyroid hormone-suppressive therapy was probably a laboratory

error. A detectable thyroglobulin level while a patient with differentiated thyroid cancer

is receiving suppressive thyroid hormone therapy usually indicates the presence of

persistent disease. This situation led us to administer a high radioiodine dose to evaluate

the situation after a post-dose whole body scan. Although we measured a thyroglobulin

concentration lower than 2 ng/mL after hyperstimulation with very high TSH levels, we

cannot be sure of the disease-free status of this patient because a very small percentage

of patients with persistent disease might have undetectable stimulated thyroglobulin

levels that become measurable after some years of followup.[36] Considering the faint

uptake observed in the thyroid bed only, it is probable that the thyroglobulin level was

produced by nonneoplastic thyroid cells that remained after the radioiodine ablation.

In Patients 2 and 3, we decided to use half of the rhTSH dose, yet quite high serum TSH

levels were still observed. The TSH levels remained elevated for at least 11 days in

Patient 1 and 12 days in Patients 2 and 3.

In the previously reported cases in which rhTSH was used in patients with renal failure,

serum TSH levels were often observed to be higher than 400 mIU/L, and 1 patient had

persistent nausea that lasted 10 days.[17,18]

We observed self-limited diarrhea in Patient 1

only. In the phase 1 study of rhTSH, headache and nausea were associated with very

high TSH levels.[37] These symptoms were not reported by any of the 3 patients in our

study. One possible reason is that nausea and headache are usually frequent symptoms

in patients with end-stage renal disease and perhaps they did not consider them to be

adverse effects.

Conclusion

The high serum TSH levels achieved after conventional and half-dose administration of

rhTSH indicate that dosage adjustments might be considered in patients with end-stage

renal disease to take into consideration that rhTSH seems to be cleared mainly by the

kidney. However, it is probable that rhTSH is a nonhemodialysed compound. The use

of a half dose (0.9 mg) divided into 2 injections seems to produce a more than

adequately high serum TSH level, but since no data are forthcoming about the

therapeutic response experienced by the patients given these 2 doses of rhTSH, it is

difficult to know if they are equivalently efficacious. In any event, we believe that it is

unlikely that a prospective study to define the correct rhTSH dose in patients with end-

stage renal disease will be performed because of the infrequent co-occurrence of

endstage renal disease and differentiated thyroid cancer. Thus, clinical decisions about

use of rhTSH and radioiodine will continue to be made on practical grounds, informed

by the accumulated published experience.

[ CLOSE WINDOW ]

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Reprint Address

Dr. Fabián Pitoia, Esmeralda 961 PB "J," (1007) Buenos Aires, Argentina. E-mail:

fpitoia@intramed.net

Abbreviation Notes

rhTSH = recombinant human thyrotropin; TSH = thyrotropin

Endocrine Practice. 2008;14(8):961-966. © 2008 American Association of Clinical

Endocrinologists