Thyroid cancer, differentiated

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For placebo or observational studies in this condition, please visit this page.
Note: these are regimens tested in histology-specific populations, please see the main thyroid cancer page for other regimens.
Last updated on 2024-07-23:11 regimens on this page
14 variants on this page
=Guidelines=
Given the rapid change in evidence in many areas of hematology/oncology, readers are encouraged to consider any guideline published 5+ years ago to be for historical purposes, only.
==ATA==
*2015: Guidelines on the management of thyroid nodules and differentiated thyroid cancer EuroPMC
==ESMO==
*2019: Filetti et al. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up EuroPMC
**2012: Pacini et al. Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up EuroPMC
**2009: Pacini et al. Differentiated thyroid cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up EuroPMC
**2008: Pacini et al. Differentiated thyroid cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up EuroPMC
==NCCN==
*NCCN does not currently have guidelines at this granular level; please see NCCN Guidelines - Thyroid Carcinoma.
=Adjuvant therapy=
==Radioiodine ablation==
===Regimen variant #1, 1.1 GBq===
Study 	Dates of enrollment	Evidence 	Comparator 	Comparative Efficacy
Schlumberger et al. 2012 (ESTIMABL1)	2007-2010 	Phase 3 (E-de-esc)	I-131; 3.7 GBq	Equivalent rate of ablation (primary endpoint)
Mallick et al. 2012 (HiLo) 	2007-2010 	Phase 3 (E-de-esc)	I-131; 3.7 GBq	Non-inferior rate of ablation (primary endpoint)
Leboulleux et al. 2022 (ESTIMABL2) 	2013-2017 	Phase 3 (C) 	Observation 	Non-inferior composite endpoint
====Preceding treatment====
*Thyroidectomy
====Radiotherapy====
*Iodine-131 1.1 GBq IV
One course
===Regimen variant #2, 3.7 GBq===
Study 	Dates of enrollment	Evidence 	Comparator 	Comparative Efficacy
Schlumberger et al. 2012 (ESTIMABL1)	2007-2010 	Phase 3 (C)	I-131; 1.1 GBq 	Equivalent outcome
Mallick et al. 2012 (HiLo) 	2007-2010 	Phase 3 (C)	I-131; 1.1 GBq 	Non-inferior rate of ablation
Ho et al. 2022 (ASTRA) 	2013-2016 	Phase 3 (C)	RAI & Selumetinib	Did not meet primary endpoint of CR rate at 18 months
====Preceding treatment====
*Thyroidectomy
====Radiotherapy====
*Iodine-131 3.7 GBq IV
One course
===Regimen variant #3, variable===
Study 	Dates of enrollment	Evidence
Maxon et al. 1983	1974-12 to 1982-07 	Non-randomized
Note: "The amount of 131I administered was arbitrarily determined by whoever was treating the patient"; included here for historic reference only.
====Preceding treatment====
*Thyroidectomy
====Radiotherapy====
*Iodine-131 IV
===References===
# Case report: Seidlin SM, Marinelli LD, Oshry E. Radioactive iodine therapy; effect on functioning metastases of adenocarcinoma of the thyroid. J Am Med Assoc. 1946 Dec 7;132(14):838-47. link to original article EuroPMC
# Maxon HR, Thomas SR, Hertzberg VS, Kereiakes JG, Chen IW, Sperling MI, Saenger EL. Relation between effective radiation dose and outcome of radioiodine therapy for thyroid cancer. N Engl J Med. 1983 Oct 20;309(16):937-41. link to original article EuroPMC
#SYTJ001T/2000: Mäenpää HO, Heikkonen J, Vaalavirta L, Tenhunen M, Joensuu H. Low vs. high radioiodine activity to ablate the thyroid after thyroidectomy for cancer: a randomized study. PLoS One. 2008 Apr 2;3(4):e1885. link to original article link to PMC article EuroPMC NCT00115895
## Update: Ahtiainen V, Vaalavirta L, Tenhunen M, Joensuu H, Mäenpää H. Randomised comparison of 1.1 GBq and 3.7 GBq radioiodine to ablate the thyroid in the treatment of low-risk thyroid cancer: a 13-year follow-up. Acta Oncol. 2020 Sep;59(9):1064-1071. Epub 2020 Jun 30. link to original article EuroPMC
# ESTIMABL1: Schlumberger M, Catargi B, Borget I, Deandreis D, Zerdoud S, Bridji B, Bardet S, Leenhardt L, Bastie D, Schvartz C, Vera P, Morel O, Benisvy D, Bournaud C, Bonichon F, Dejax C, Toubert ME, Leboulleux S, Ricard M, Benhamou E; Tumeurs de la Thyroïde Refractaires Network for the Essai Stimulation Ablation Equivalence Trial. Strategies of radioiodine ablation in patients with low-risk thyroid cancer. N Engl J Med. 2012 May 3;366(18):1663-73. link to original article EuroPMC NCT00435851
## Update: Schlumberger M, Leboulleux S, Catargi B, Deandreis D, Zerdoud S, Bardet S, Rusu D, Godbert Y, Buffet C, Schvartz C, Vera P, Morel O, Benisvy D, Bournaud C, Toubert ME, Kelly A, Benhamou E, Borget I. Outcome after ablation in patients with low-risk thyroid cancer (ESTIMABL1): 5-year follow-up results of a randomised, phase 3, equivalence trial. Lancet Diabetes Endocrinol. 2018 Aug;6(8):618-626. Epub 2018 May 26. link to original article EuroPMC
# HiLo: Mallick U, Harmer C, Yap B, Wadsley J, Clarke S, Moss L, Nicol A, Clark PM, Farnell K, McCready R, Smellie J, Franklyn JA, John R, Nutting CM, Newbold K, Lemon C, Gerrard G, Abdel-Hamid A, Hardman J, Macias E, Roques T, Whitaker S, Vijayan R, Alvarez P, Beare S, Forsyth S, Kadalayil L, Hackshaw A. Ablation with low-dose radioiodine and thyrotropin alfa in thyroid cancer. N Engl J Med. 2012 May 3;366(18):1674-85. link to original article dosing details in abstract have been reviewed by our editors EuroPMC NCT00415233
#ASTRA: Ho AL, Dedecjus M, Wirth LJ, Tuttle RM, Inabnet WB 3rd, Tennvall J, Vaisman F, Bastholt L, Gianoukakis AG, Rodien P, Paschke R, Elisei R, Viola D, So K, Carroll D, Hovey T, Thakre B, Fagin JA; ASTRA investigator group. Selumetinib Plus Adjuvant Radioactive Iodine in Patients With High-Risk Differentiated Thyroid Cancer: A Phase III, Randomized, Placebo-Controlled Trial (ASTRA). J Clin Oncol. 2022 Jun 10;40(17):1870-1878. Epub 2022 Feb 22. link to original article dosing details in abstract have been reviewed by our editors link to PMC article EuroPMC NCT01843062
#ESTIMABL2: Leboulleux S, Bournaud C, Chougnet CN, Zerdoud S, Al Ghuzlan A, Catargi B, Do Cao C, Kelly A, Barge ML, Lacroix L, Dygai I, Vera P, Rusu D, Schneegans O, Benisvy D, Klein M, Roux J, Eberle MC, Bastie D, Nascimento C, Giraudet AL, Le Moullec N, Bardet S, Drui D, Roudaut N, Godbert Y, Morel O, Drutel A, Lamartina L, Schvartz C, Velayoudom FL, Schlumberger MJ, Leenhardt L, Borget I. Thyroidectomy without Radioiodine in Patients with Low-Risk Thyroid Cancer. N Engl J Med. 2022 Mar 10;386(10):923-932. link to original article dosing details in abstract have been reviewed by our editors EuroPMC NCT01837745
##Update: Leboulleux S, Bournaud C, Chougnet CN, Lamartina L, Zerdoud S, Do Cao C, Catargi B, Dygai I, Kelly A, Barge ML, Vera P, Rusu D, Schneegans O, Roux J, Raymond P, Benisvy D, Eberle MC, Bidault S, Nascimento C, Bastie D, Giraudet AL, Bardet S, Le Moullec N, Roudaut N, Drui D, Godbert Y, Zalzali M, Drutel A, Morel O, Velayoudom FL, Al Ghuzlan A, Schlumberger M, Buffet C, Borget I. Thyroidectomy without radioiodine in patients with low-risk thyroid cancer: 5 years of follow-up of the prospective randomised ESTIMABL2 trial. Lancet Diabetes Endocrinol. 2025 Jan;13(1):38-46. Epub 2024 Nov 22. link to original article EuroPMC
==Radioiodine & Selumetinib==
===Regimen===
Study 	Dates of enrollment	Evidence
Ho et al. 2013 (MSK 09-048)	2010-2011 	Non-randomized
====Radiotherapy====
*Iodine-131 (dose not specified) IV
====Targeted therapy====
*Selumetinib (Koselugo) 75 mg PO twice per day on days 1 to 28
4-week course
===References===
# MSK 09-048: Ho AL, Grewal RK, Leboeuf R, Sherman EJ, Pfister DG, Deandreis D, Pentlow KS, Zanzonico PB, Haque S, Gavane S, Ghossein RA, Ricarte-Filho JC, Domínguez JM, Shen R, Tuttle RM, Larson SM, Fagin JA. Selumetinib-enhanced radioiodine uptake in advanced thyroid cancer. N Engl J Med. 2013 Feb 14;368(7):623-32. link to original article link to PMC article EuroPMC NCT00970359
=Advanced or metastatic disease, radioactive iodine-refractory=
==Apatinib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence 	Comparator	Comparative Efficacy
Lin et al. 2022 (REALITY)	2017-2020 	Phase 3 (E-esc)	Placebo 	Seems to have longer OS (secondary endpoint)Median OS: NYR vs 29.9 mo(HR 0.42, 95% CI 0.18-0.97)
====Targeted therapy====
*Apatinib (Aitan) 500 mg PO once per day on days 1 to 28
28-day cycles
===References===
#REALITY: Lin Y, Qin S, Li Z, Yang H, Fu W, Li S, Chen W, Gao Z, Miao W, Xu H, Zhang Q, Zhao X, Bao J, Li L, Ren Y, Lin C, Jing S, Ma Q, Liang J, Chen G, Zhang H, Zhang Y, Zhou X, Sang Y, Hou Z. Apatinib vs Placebo in Patients With Locally Advanced or Metastatic, Radioactive Iodine-Refractory Differentiated Thyroid Cancer: The REALITY Randomized Clinical Trial. JAMA Oncol. 2022 Feb 1;8(2):242-250. link to original article link to PMC article dosing details in manuscript have been reviewed by our editors EuroPMC NCT03048877
==Cabozantinib monotherapy==
===Regimen variant #1, pediatric dosing===
FDA-recommended dose
Note: this is the FDA-recommended dose in pediatric patients who are 12 years of age or older with BSA less than 1.2 m2.
====Targeted therapy====
*Cabozantinib (Cometriq) 40 mg PO once per day
Continued indefinitely
===Regimen variant #2===
FDA-recommended dose
Study 	Dates of enrollment 	Evidence 	Comparator	Comparative Efficacy
Brose et al. 2021 (COSMIC-311)	2019-02-27 to 2020-08-18	Phase 3 (E-RT-esc)	Placebo 	Longer PFS1 (co-primary endpoint)Median PFS: 11 vs 1.9 mo(HR 0.22, 96% CI 0.15-0.32)
1Reported efficacy is based on the 2022 update.
Note: this is the FDA-recommended dose for adult patients.
====Targeted therapy====
*Cabozantinib (Cometriq) 60 mg PO once per day on days 1 to 28
28-day cycles
===References===
# COSMIC-311: Brose MS, Robinson B, Sherman SI, Krajewska J, Lin CC, Vaisman F, Hoff AO, Hitre E, Bowles DW, Hernando J, Faoro L, Banerjee K, Oliver JW, Keam B, Capdevila J. Cabozantinib for radioiodine-refractory differentiated thyroid cancer (COSMIC-311): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Oncol. 2021 Aug;22(8):1126-1138. Epub 2021 Jul 5. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT03690388
##Update: Brose MS, Robinson BG, Sherman SI, Jarzab B, Lin CC, Vaisman F, Hoff AO, Hitre E, Bowles DW, Sen S, Oliver JW, Banerjee K, Keam B, Capdevila J. Cabozantinib for previously treated radioiodine-refractory differentiated thyroid cancer: Updated results from the phase 3 COSMIC-311 trial. Cancer. 2022 Dec 15;128(24):4203-4212. Epub 2022 Oct 19. Erratum in: Cancer. 2023 Mar 1;129(5):807. link to original article link to PMC article EuroPMC
==Donafenib monotherapy==
===Regimen===
Study 	Dates of enrollment 	Evidence 	Comparator	Comparative Efficacy
Lin et al. 2023 (ZGDD3)	2018-08-29 to 2021-02-28	Phase 3 (E-esc)	Placebo 	Longer PFS (primary endpoint)Median PFS: 12.9 vs 6.4 mo(HR 0.39, 95% CI 0.25-0.61)
====Targeted therapy====
*Donafenib (Zepsun) 300 mg PO twice per day on days 1 to 28
28-day cycles
===References===
#ZGDD3: Lin Y, Qin S, Yang H, Shi F, Yang A, Han X, Liu B, Li Z, Ji Q, Tang L, Deng Z, Ding Y, Fu W, Xie X, Li L, He X, Lv Z, Ma Q, Shen Z, Guo Z, Chen Z, Cui Y, Tan J, Gao Z, Jing S, Lu K, Luo X, Zhang Y, Fang Y, Li Z, Cheng Y, Lei S, Luan S, Chen G, Wang G, Wu L, Liu L. Multicenter Randomized Double-Blind Phase III Trial of Donafenib in Progressive Radioactive Iodine-Refractory Differentiated Thyroid Cancer. Clin Cancer Res. 2023 Aug 1;29(15):2791-2799. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT03602495
==Lenvatinib monotherapy==
===Regimen===
Study 	Dates of enrollment 	Evidence 	Comparator	Comparative Efficacy
Schlumberger et al. 2015 (SELECT) 	2011-08-05 to 2012-10-04	Phase 3 (E-RT-esc)	Placebo 	Longer PFS (primary endpoint)Median PFS: 18.3 vs 3.6 mo(HR 0.21, 99% CI 0.14-0.31)
Zheng et al. 2021 (E7080-C086-308)	2017 to not reported 	Phase 3 (E-esc) 	Placebo 	Longer PFS (primary endpoint)Median PFS: 23.9 vs 3.7 mo(HR 0.16, 95% CI 0.10-0.26)
====Targeted therapy====
*Lenvatinib (Lenvima) 24 mg PO once per day on days 1 to 28
28-day cycles
====Dose and schedule modifications====
*Per the package insert, patients with eGFR of less than 30 mL/min/1.73m2 by Cockroft-Gault or Child-Pugh C severe hepatic impairment should receive 14 mg PO once per day.
===References===
# SELECT: Schlumberger M, Tahara M, Wirth LJ, Robinson B, Brose MS, Elisei R, Habra MA, Newbold K, Shah MH, Hoff AO, Gianoukakis AG, Kiyota N, Taylor MH, Kim SB, Krzyzanowska MK, Dutcus CE, de las Heras B, Zhu J, Sherman SI. Lenvatinib versus placebo in radioiodine-refractory thyroid cancer. N Engl J Med. 2015 Feb 12;372(7):621-30. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT01321554
#E7080-C086-308: Zheng X, Xu Z, Ji Q, Ge M, Shi F, Qin J, Wang F, Chen G, Zhang Y, Huang R, Tan J, Huang T, Li S, Lv Z, Lin Y, Guo Z, Kubota T, Suzuki T, Ikezawa H, Gao M. A Randomized, Phase III Study of Lenvatinib in Chinese Patients with Radioiodine-Refractory Differentiated Thyroid Cancer. Clin Cancer Res. 2021 Oct 15;27(20):5502-5509. Epub 2021 Jul 29. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article EuroPMC NCT02966093
==Pazopanib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence	Efficacy
Bible et al. 2010 (MC057H)	2008-2009 	Phase 2 	ORR: 49%, 95% CI 35-68
====Targeted therapy====
*Pazopanib (Votrient) 800 mg PO once per day on days 1 to 28
28-day cycles
===References===
# MC057H: Bible KC, Suman VJ, Molina JR, Smallridge RC, Maples WJ, Menefee ME, Rubin J, Sideras K, Morris JC 3rd, McIver B, Burton JK, Webster KP, Bieber C, Traynor AM, Flynn PJ, Goh BC, Tang H, Ivy SP, Erlichman C; Endocrine Malignancies Disease Oriented Group; Mayo Clinic Cancer Center; Mayo Phase 2 Consortium. Efficacy of pazopanib in progressive, radioiodine-refractory, metastatic differentiated thyroid cancers: results of a phase 2 consortium study. Lancet Oncol. 2010 Oct;11(10):962-72. Epub 2010 Sep 17. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article EuroPMC NCT00625846
==Sorafenib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence 	Comparator	Comparative Efficacy
Brose et al. 2014 (DECISION)	2009-2011 	Phase 3 (E-RT-esc)	Placebo 	Longer PFS (primary endpoint)Median PFS: 10.8 vs 5.8 mo(HR 0.59, 95% CI 0.45-0.76)
====Targeted therapy====
*Sorafenib (Nexavar) 400 mg PO twice per day on days 1 to 28
28-day cycles
===References===
# DECISION: Brose MS, Nutting CM, Jarzab B, Elisei R, Siena S, Bastholt L, de la Fouchardiere C, Pacini F, Paschke R, Shong YK, Sherman SI, Smit JW, Chung J, Kappeler C, Peña C, Molnár I, Schlumberger MJ; DECISION investigators. Sorafenib in radioactive iodine-refractory, locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 3 trial. Lancet. 2014 Jul 26;384(9940):319-28. Epub 2014 Apr 24. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article EuroPMC NCT00984282
==Sunitinib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence	Efficacy
Carr et al. 2010	2007-2009 	Phase 2 	ORR: 31% (95% CI: 16-47)
====Targeted therapy====
*Sunitinib (Sutent) 37.5 mg PO once per day on days 1 to 42
42-day cycles
===References===
# Carr LL, Mankoff DA, Goulart BH, Eaton KD, Capell PT, Kell EM, Bauman JE, Martins RG. Phase II study of daily sunitinib in FDG-PET-positive, iodine-refractory differentiated thyroid cancer and metastatic medullary carcinoma of the thyroid with functional imaging correlation. Clin Cancer Res. 2010 Nov 1;16(21):5260-8. Epub 2010 Sep 16. link to original article dosing details in manuscript have been reviewed by our editors link to PMC article EuroPMC
==Vandetanib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence 	Comparator	Comparative Efficacy
Leboulleux et al. 2012 (D4200C00079)	2007-2008 	Randomized Phase 2 (E-esc)	Placebo 	Longer PFS (primary endpoint)Median PFS: 11.1 vs 5.9 mo(HR 0.63, 60% CI 0.54-0.74)
Brose et al. 2024 (VERIFY) 	2013-2015 	Phase 3 (E-esc) 	Placebo 	Might have longer PFS (primary endpoint)Median PFS: 10 vs 5.7 mo(HR 0.75, 95% CI 0.55-1.03)
====Targeted therapy====
*Vandetanib (Caprelsa) 300 mg PO once per day
Continued indefinitely
===References===
# D4200C00079: Leboulleux S, Bastholt L, Krause T, de la Fouchardiere C, Tennvall J, Awada A, Gómez JM, Bonichon F, Leenhardt L, Soufflet C, Licour M, Schlumberger MJ. Vandetanib in locally advanced or metastatic differentiated thyroid cancer: a randomised, double-blind, phase 2 trial. Lancet Oncol. 2012 Sep;13(9):897-905. Epub 2012 Aug 14. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT00537095
#VERIFY: Brose MS, Capdevila J, Elisei R, Bastholt L, Führer-Sakel D, Leboulleux S, Sugitani I, Taylor MH, Wang Z, Wirth LJ, Worden FP, Bernard J, Caferra P, Colzani RM, Liu S, Schlumberger M. Vandetanib in locally advanced or metastatic differentiated thyroid cancer refractory to radioiodine therapy. Endocr Relat Cancer. 2024 Jul 2;31(8):e230354. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT01876784
=Advanced or metastatic disease, all lines of therapy=
==Axitinib monotherapy==
===Regimen===
Study 	Dates of enrollment	Evidence	Efficacy
Locati et al. 2014 (A4061027)	2006-2008 	Phase 2 	ORR: 35%, 95% CI 22-49
====Targeted therapy====
*Axitinib (Inlyta) 5 mg PO twice per day
Continued indefinitely
===References===
# A4061027: Locati LD, Licitra L, Agate L, Ou SH, Boucher A, Jarzab B, Qin S, Kane MA, Wirth LJ, Chen C, Kim S, Ingrosso A, Pithavala YK, Bycott P, Cohen EE. Treatment of advanced thyroid cancer with axitinib: Phase 2 study with pharmacokinetic/pharmacodynamic and quality-of-life assessments. Cancer. 2014 Sep 1;120(17):2694-703. Epub 2014 May 20. link to original article dosing details in manuscript have been reviewed by our editors EuroPMC NCT00389441
Category:Thyroid cancer regimens
Category:Histology-specific pages
Category:Endocrine cancers
Category:Head and neck cancers