SAT559 Challenges Involved in Managing a Paraplegic Patient with Metastatic Papillary Thyroid Cancer Requiring Radioactive Iodine Therapy
Authors: Al-Naqeeb Ghadah , Munger Eric , Veeraraghavan Padmasree , Cochran Craig , Bernaldez Philip , Wong Paul , Devaraj Newbegin , Fisher Teresa , Lee Korressa , Owoade Olumide , Jones Iman , Gubbi Sriram , Klubo-Gwiezdzinska Joanna 
Published: October 2023

Abstract
Disclosure: G. Al-Naqeeb: None. E. Munger: None. P. Veeraraghavan: None. C. Cochran: None. P. Bernaldez: None. P. Wong: None. N. Devaraj: None. T. Fisher: None. K. Lee: None. O. Owoade: None. I. Jones: None. S. Gubbi: None. J. Klubo-Gwiezdzinska: None.
Background: High radioactive iodine (RAI) therapy doses utilized for treating thyroid cancer patients require a 24-48-hour radiation isolation period until the total effective dose equivalent exposure (TEDE) to the general population does not exceed 5mSv. We present a unique scenario of a paraplegic patient with metastatic papillary thyroid cancer (PTC) requiring RAI therapy and the radiation precaution strategies implemented by our team to reduce radiation exposure risk to the medical staff.A 69-year-old female with RAI-refractory tall cell-variant PTC (pT4aN1bM1; BRAF V600E pathogenic variant) with pulmonary metastases, paraplegia due to a motor vehicle accident with neurogenic bowel and bladder, was referred to our center for management of PTC. Laboratory data revealed a serum thyroglobulin of 2313 ng/mL (normal=1.6-59.9), and anatomical imaging showed numerous pulmonary nodules that had increased in size and number compared to prior imaging from 6 months ago. Due to disease progression, re-differentiation therapy with dabrafenib was initiated. After 3-months of dabrafenib therapy, a diagnostic thyroid hormone withdrawal-aided 131I scan with dosimetry revealed a significant re-induction of RAI uptake in pulmonary lesions and it was determined that therapy with an RAI dose of 200 mCi would not exceed a safe radiation exposure to the bone marrow of 200 rads. A multi-step mitigation strategy was developed based on a multidisciplinary team meeting and appropriate mock sessions. Stay times were estimated for individuals based on historical TEDE following the care of non-paralyzed patients receiving similarly prescribed activity. To minimize exposure to nursing staff, the patient’s Foley catheter was shielded with lead lining and bowels were emptied the night before RAI with a laxative. For each entry, posted safety sheets were updated with one-foot and one-meter isodose lines and on-contact exposure rates. Two nurses and one radiation safety staff member donned full personal protective equipment (PPE; full body suit, double gloves, booties, face covering) in the staging area and entered via lane one. While nursing provided direct care needs, radiation safety staff emptied the shielded catheter, organized clutter and packaged radioactive waste containers. Upon completion of duties, staff exited via lane two, removed PPE, and performed a full personnel contamination survey in the staging area. The patient successfully underwent RAI therapy with 200 mCi. Six months later the serum thyroglobulin had reduced to 48.4ng/ml with a substantial reduction in pulmonary metastatic tumor burden on imaging studies. Conclusion: Post-RAI therapy care of paralyzed patients during radiation isolation poses a unique challenge to medical staff warranting modifications in routine care practices, which can be achieved safely through optimal planning and enhanced training.
Presentation Date: Saturday, June 17, 2023