Journal of Surgical Oncology 2012;105:622 LETTER TO THE EDITOR Adding Surgery as a Complementary Approach to Radioiodine Therapy in Patients of Differentiated Thyroid Carcinoma With Large Solitary Flat Bone Metastases: The Unresolved Issues SANDIP BASU,* AMIT ABHYANKAR Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India A particularly challenging setting in the management of metastatic thyroid carcinoma is treatment of large flat bone metastases. Radio- iodine therapy, the primary treatment modality for metastatic thyroid carcinoma, has also been utilized as the cornerstone in the management of these patients, however, almost never a complete remission can be achieved with I-131 ablation therapy alone. Hence, very often the aim of the treating physician is to stabilize the disease with multiple radio- iodine therapies. Surgical resection of osseous metastases has been advocated by some investigators [1–5], particularly in the setting of solitary osseous metastases and have been claimed to better the prognosis and quality of life. We believe, from our practical experience at a large tertiary care centre, that surgery can be utilized as valuable adjunct to 131-I therapy in this group of patients. Not infrequently, these metastatic lesions become iodine non-concentrating following multiple therapies due to the development of subpopulation of non- iodine concentrating cells within the tumor, which are usually iodine refractory. Furthermore, we found this approach extremely useful and may also be extended, on a case-to-case basis, to patients who have relatively few low volume lesions at other sites. Presently, however, this is employed rather erratically without any clear-cut consensus and approach existing on a sound evidence base. Hence a number of issues need to be addressed before this approach can have an invaluable role in selected, individual patients, (a) What is the optimum time for such surgical extirpation in these patients? Should this be considered upfront or employed after a few sittings of I- 131 therapy? Frequently, the large flat bone metastases are very vascular which can render surgery to be a challenging task with risk of bleeding. Also at initial diagnosis, the lesions of well-differentiated carcinoma, frequently appear as radioiodine avid and may demonstrate partial response and sclerosis on radiography following one or two high dose therapies with 131-I. This could be the time when one would find it appropriate to surgically intervene. A judicious mix of 131-I and surgery, we believe, is crucial to obtain the best results in this setting. A critical appraisal of this issue needs to be undertaken. (b) Secondly, whether the surgical approach can also be extended to patients with low volume metastatic disease at few other sites? This would aid in more effective delivery of 131-I to the remaining metastatic sites in addition to providing substantial symptomatic palliation due to debulking of the large and frequently vascular tumor. We have observed from our practical experience where large sternal mass excised for symptomatic palliation, even, in the presence of a few other lesions, have resulted in excellent disease control and symptom free survival. (c) Thirdly, whether complete surgical resection as a therapeutic option, results in prolonged survival required to be determined. The initial few reports appeared favorable but more data require to be accrued before a definitive conclusion can be drawn. Such data hopefully will be generated in future multicentric clinical trials and collaborative research, which can optimize this approach further and make this an important option available to the attending physician for this difficult clinical presentation. REFERENCES 1. Zettinig G, Fueger BJ, Passler C, et al.: Long-term follow-up of patients with bone metastases from differentiated thyroid carci- noma—Surgery or conventional therapy? Clin Endocrinol (Oxf) 56:377–382. 2. Niederle B, Roka R, Schemper M, et al.: Surgical treatment of distant metastases in differentiated thyroid cancer: Indication and results. Surgery 100:1088–1097. 3. Bernier MO, Leenhardt L, Hoang C, et al.: 2001; Survival and therapeutic modalities in patients with bone metastases of differ- entiated thyroid carcinomas. J Clin Endocrinol Metab 86:1568– 1573. 4. Mishra A, Mishra SK, Agarwal A, et al.: Surgical treatment of sternal metastases from thyroid carcinoma: Report of two cases. Surg Today 31:799–802. 2001. 5. Lequaglie C, Massone PP, Giudice G, et al.: Analysis and long-term survival in sternectomy with plastic reconstruction for primary and secondary neoplasms of the sternum. Chir Ital 53:485–494. 2001. Conflict of interest: none declared. *Correspondence to: Sandip Basu, Radiation Medicine Centre (B.A.R.C) T.M.C Annexe, Jerbai Wadia Road, Parel, Mumbai 400012, India Tel: Office: 022 24146059, 24135232, 24149428 Fax: 022 24157098. E-mail: drsanb@yahoo.com Received 10 September 2011; Accepted 19 September 2011 DOI 10.1002/jso.22116 Published online 17 October 2011 in Wiley Online Library (wileyonlinelibrary.com). ß 2011 Wiley Periodicals, Inc.