Although there is a trend toward higher ablation rates with higher activities [
25,
26], activities between 30 and 100 mCi of
131I generally show similar rates of successful remnant ablation [
27‐
30]. A randomized study using preparation with rhTSH showed that ablation rates were comparable with 50 mCi compared to 100 mCi [
31]. A prospective, randomized study performed in 160 patients, comparing ablation with 30 and 100 mCi, after preparation with thyroid hormone withdrawal, found no difference in both the ablation rate and in the rate or recurrence during follow-up [
32]. Recently, two prospective randomized studies in very large number of patients conducted in France and in the United Kingdom found no significant difference in the remnant ablation rate using 30 or 100 mCi of
131I, either after preparation with thyroid hormone withdrawal or rhTSH [
16,
17]. It is worth noting, that these two studies included not only low-risk patients, but also patients at intermediate risk of recurrence, including those showing minimal extrathyroidal extension of the primary tumor [
17] or lymph node metastases [
16,
17]. Also in this category the authors found no difference between low- and high-RAI doses in terms of ablation success rates. This finding has been confirmed in a retrospective study including only patients at intermediate risk, treated with low- or high-RAI activities [
33]. In this study, the authors were also able to demonstrate that, with regard to recurrences or deaths, the long-term outcome was not affected by the ablation dose (low or high). Concerning the issue of the follow-up of patients treated with low activity of 131-I and rhTSH or LT4 withdrawal, a recent study [
19] showed that in 10 years of follow-up, the rate of recurrence was as low as expected (3.5 %) and similar in both groups. Moreover, the final outcome of these patients was similar at the end of follow-up (Table
1).
Table 1
Guidelines for radioiodine thyroid ablation
Preparation for RAI ablation | 1. Patients undergoing RAI ablation should be preferentially prepared by rhTSH administration [ 14, 16, 17] | A |
Which is the best activity of 131I to be employed for post-surgical thyroid remnant ablation | 2. The minimum activity (30 mCi) necessary to achieve successful remnant ablation should be utilized, particularly in patients at low risk and intermediate risk [ 31‐ 33] | B |
3. In patients considered at high risk for recurrence, or if residual microscopic disease is suspected or documented, higher activities (100 mCi or more) should be considered [ 40] | C |
Diagnostic RAI scanning before ablation | 4. Pre-ablation diagnostic scans are seldom informative as far as the decision to ablate is concerned. They may be considered when a sustained suspicion of local or distant metastases is present to better define the activity of RAI to be administered or in patients with elevated levels of serum TgAb [ 38, 40‐ 42] | C |
Post-operative serum Tg levels and neck US | 5. Post-operative serum Tg levels (in the absence of serum TgAb) and neck US may give additional information regarding the need for ablation and the radioiodine dose to be administered [ 47, 48] | C |
Is a low-iodine diet necessary before remnant ablation? | 6. At least in countries with mild or moderate iodine deficiency, there is no need to prescribe a low-iodine diet before remnant ablation. Avoidance of iodine-containing drugs or contrast agents is mandatory [ 53] | B |
Post-therapy WBS after remnant ablation | 7. A post-therapy WBS is recommended following remnant ablation. This is typically done 3–7 days after the therapeutic dose is administered [ 54, 55] | A |