Long-term efficacy of lenvatinib for recurrent papillary thyroid carcinoma after multimodal treatment and management of complications: a case report

Abstract

Background: The advent of tyrosine kinase inhibitors (TKIs) has changed the treatment of RAI refractory, unresectable recurrent differentiated thyroid cancer (DTC), which was formerly treated with multidisciplinary remedies.

Case presentation: Here we describe the case of a 64-year-old woman who underwent total thyroidectomy with tracheal resection and suffered from a recurrent tumor in the neck and multiple lung and bone metastases 3 and 11 months, respectively, after the operation. Multimodal therapies, RI (I-131), EBRT, and taxane-based chemotherapy were ineffective, and sorafenib was started as a TKI. However, because of disease progression, sorafenib was replaced by lenvatinib after 9 months. The effect of lenvatinib has continued for more than 1 year and 9 months, and the patient has well survived. During the treatment period, a tracheal pin-hole fistula suddenly emerged, which was naturally cured by the temporary cessation of lenvatinib. Adverse events such as hypertension, proteinuria, and diabetes as innate complications have been successfully managed until the present according to our institute regulations.

Conclusions: Even where multimodal treatment was ineffective, lenvatinib was suggested to be an alternative treatment option for RAI refractory recurrent DTC and patient could have a chance to be controlled successfully.

Keywords: Lenvatinib; Multimodal treatment; Papillary thyroid cancer; Tracheal perforation; Tyrosine kinase inhibitor.

Fig. 1

a and b Enhanced CT findings before operation. The tumor (arrow) was mainly located in the left lobe and invaded into half the tracheal circumference (40 × 36 mm) (Fig.2(A)). c and d Recurrent tumor was found just below the left piriform fossa (15 × 11 mm) (c), and lung metastasis (max, 6 mm) (d) was found at the same time 3 months after the operation by CT scan (Fig.2(B)). e, f, and g Nine months after the operation, CT scan showed prominent tumor progression in the neck (48 × 38 mm) (e) and the lung (18 × 16 mm) (f). Additionally, bone scintigraphy demonstrated a solitary bone metastasis in the right scapula (g) (Fig.2(C)). h and i Three years after the operation, local recurrence in the neck was controlled (15 × 11 mm) (h), although multiple metastasis in the lung worsened (PD). Maximum size was 30 × 26 mm (i) (Fig.2(D)). j and k Within 8 months after starting sorafenib, local recurrence (j) and lung metastasis worsened (PD) (k) (Fig.2(E)). l and m Within 1 month after starting lenvatinib, the tumor in the neck remained controlled (l) and multiple metastases in the lung decreased and diminished in size (18 × 15 mm) (m) (PR) (Fig.2(F)). n Within 3 months after starting lenvatinib, pin-hole perforation (5 mm) of the trachea suddenly appeared at the end of tracheal invasion (Fig.2(G)). o Within 1 month after terminating lenvatinib, the perforation was naturally cured and pin-hole closed (Fig.2(H)). p and q Within 2 months after restarting lenvatinib, tumors in the neck (p) and the lung (q) were controlled (PR) (Fig.2(I)). r and sAlthough local recurrence (r) was kept controlled, lung metastasis (s) was exacerbated (21 × 18 mm) for 2 months after terminating lenvatinib because of adverse events (PD) (Fig.2(J)). tand uWithin 3 months after restarting lenvatinib, local recurrence in the neck (t) and lung metastasis (u) remained under control (PR) (Fig.2(K)). v and w One year and 9 months after starting lenvatinib, CT scan still showed PR (Fig.2(L))

Fig. 2

Time-course result of patient remedy and effect, including thyroglobulin level. Alphabets in the figures (shown in red, such as (A)) correspond to the alphabets in Fig. 1