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"documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Med Clin. 2015;144:42-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 112 "formatos" => array:2 [ "HTML" => 96 "PDF" => 16 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Study of hidden hepatitis B in African immigrant people without data of liver disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "42" "paginaFinal" => "43" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio de hepatitis B oculta en población inmigrante africana sin datos de hepatopatía" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Ángel Cuenca-Gómez, M. Teresa Cabezas-Fernández, Manuel Jesús Soriano-Pérez, Joaquín Salas-Coronas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "José Ángel" "apellidos" => "Cuenca-Gómez" ] 1 => array:2 [ "nombre" => "M. 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"documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Med Clin. 2015;144:30-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 253 "formatos" => array:2 [ "HTML" => 116 "PDF" => 137 ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "The motor organization of cerebral cortex and the role of the mirror neuron system. Clinical impact for rehabilitation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "30" "paginaFinal" => "34" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Organización motora del córtex cerebral y el papel del sistema de las neuronas espejo. Repercusiones clínicas para la rehabilitación" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Laia Sallés, Xavier Gironès, José Vicente Lafuente" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Laia" "apellidos" => "Sallés" ] 1 => array:2 [ "nombre" => "Xavier" "apellidos" => "Gironès" ] 2 => array:2 [ "nombre" => "José Vicente" "apellidos" => "Lafuente" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775314000700" "doi" => "10.1016/j.medcli.2013.12.013" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775314000700?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020615000066?idApp=UINPBA00004N" "url" => "/23870206/0000014400000001/v1_201509042040/S2387020615000066/v1_201509042040/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Postoperative radioiodine ablation in patients with low risk differentiated thyroid carcinoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "35" "paginaFinal" => "41" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Juan J. Díez, Enrique Grande, Pedro Iglesias" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Juan J." "apellidos" => "Díez" "email" => array:1 [ 0 => "juanjose.diez@salud.madrid.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Enrique" "apellidos" => "Grande" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Pedro" "apellidos" => "Iglesias" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universidad de Alcalá de Henares, Alcalá de Henares, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oncología Médica, Hospital Ramón y Cajal, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ablación posquirúrgica con radioyodo en pacientes con carcinoma diferenciado de tiroides de bajo riesgo" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Radioiodine (RI) has been used since the 40s due to the ability of thyroid follicular cells to capture and concentrate this element through the sodium-iodide transporter.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1,2</span></a><span class="elsevierStyleItalic">RI ablation</span> (RIA) refers to the first administration of this radio drug in a patient with differentiated thyroid carcinoma (DTC) in order to remove the thyroid tissue remnants left after total thyroidectomy. This procedure is generally used 4–8 weeks after surgery and must not be confused with <span class="elsevierStyleItalic">RI treatment</span>, which refers to the administration of therapeutic doses of RI in patients with persistent or recurrent disease after a proper surgical treatment, in order to destroy macroscopic structural disease.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Total thyroidectomy followed by RIA and thyroid hormone suppressive treatment improves the overall survival of patients with medium-to-high risk DTC.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> However, there is an important group of patients with low-risk DTC that have an excellent prognosis, even without RIA, and represent almost 50% of all the thyroid cancer cases currently.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The selection of patients that need not receive RIA and the dosage required are controversial subjects. Clinical guidelines recognise that there are groups of patients in which the indication is mandatory, others in which its use is selective and, finally, others in which it must not be administrated.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">2,5–7</span></a> The controversy began when some authors showed that some low-risk patients with theoretically no RIA indication might present lymph node metastases and other characteristics that increase the risk of recurrence during follow-up.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">4,8</span></a> This article analyses the basics of RIA, its advantages and disadvantages and, finally, the current criteria for the indication or lack of indication for this procedure in patients with low-risk DTC.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition of low-risk patient</span><p id="par0020" class="elsevierStylePara elsevierViewall">It is important not to confuse the risk of mortality with the risk of recurrence of the disease. The TNM staging system<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">9</span></a> is given to patients in 4 stages and is used to assess overall and specific mortality (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Stage <span class="elsevierStyleSmallCaps">i</span> includes patients <45 years without distant metastases and patients ≥45 years with tumours ≤2<span class="elsevierStyleHsp" style=""></span>cm without lymph node or distant metastases. In patients <45 years, stage <span class="elsevierStyleSmallCaps">ii</span> is defined by the presence of distant metastases, while in older patients, stage <span class="elsevierStyleSmallCaps">ii</span> includes tumours of up to 4<span class="elsevierStyleHsp" style=""></span>cm without lymphatic or distant metastases.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">9</span></a> Low-risk patients are those included in stages <span class="elsevierStyleSmallCaps">i</span> and <span class="elsevierStyleSmallCaps">ii</span> of the <span class="elsevierStyleItalic">American Joint Committee on Cancer</span> without distant metastases, since they practically have a 100% survival after 5 years.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">However, to estimate the risk of persistence or recurrence of the disease, other clinical and histological parameters are used.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">5,6</span></a> The European Consensus defines very low-risk and low-risk patients pursuant to the characteristics shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. These patients have a long-term recurrence rate lower than 2%.<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1,5</span></a> The <span class="elsevierStyleItalic">American Thyroid Association</span> (ATA) classifies the risk of recurrence as low, intermediate and high.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a> The patients from the first group present a risk of recurrence of 3%.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Basics of radioiodine ablation</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objectives</span><p id="par0030" class="elsevierStylePara elsevierViewall">RIA is a form of radioisotope treatment used after a total thyroidectomy, with the objectives included in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. In low-risk patients, the objective of RIA is to remove all the remaining normal thyroid tissue, as well as to destroy possible microscopic tumour remnants not removed during surgery, in order to facilitate the follow-up of the patient with serum thyroglobulin (Tg) determination and full body scans. The Tg is a specific marker of tumour recurrence in patients treated with surgery followed by RIA.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In patients with intermediate or high risk, RIA is a form of adjuvant treatment whose objective is to treat the postoperative or metastatic residual disease, as well as to conduct a full body scan 2–5 days after the RIA for the assessment of the distant disease with a higher sensitivity than scans with diagnostic doses.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Preparation</span><p id="par0040" class="elsevierStylePara elsevierViewall">The preparation of the patient requires a diet low in iodine (<50<span class="elsevierStyleHsp" style=""></span>μg/day) during the 2–3 weeks prior, no iodine medication, and thyrotropin (TSH) serum levels above 30<span class="elsevierStyleHsp" style=""></span>mI/U to achieve sufficient RI capture in the healthy or tumour thyroid tissue remnants.<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> An increase in TSH can be achieved by an increase in endogenous TSH through the withdrawal of the treatment with levothyroxine during 4–6 weeks or the administration of recombinant human TSH (rhTSH) (2 injections of 0.9<span class="elsevierStyleHsp" style=""></span>mg during 2 consecutive days).<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1,2</span></a> The advantages of using rhTSH include improvements in the quality of life of patients by avoiding the symptoms of hypothyroidism<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">13,14</span></a> and a reduced exposure to radiation of the extrathyroidal tissues, since the clearance of RI is quicker than in the case of hypothyroidism.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> Pregnancy must be avoided during the administration of RI and during the following 6–12 months.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">5,6,16</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dosage and activity</span><p id="par0045" class="elsevierStylePara elsevierViewall">Ablation is generally achieved when the dose absorbed by the thyroid remnant is equal to or higher than 300<span class="elsevierStyleHsp" style=""></span>Gy.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a> To estimate the activity of RI required by each patient to achieve this dose, two methods are used: the empirical method and the dosimetric method. The first one is based on the experience and the assessment of several factors, such as the patient's age, the tumour size and histology, the presence of extrathyroidal extension and metastasis. It uses fixed activities ranging from 30 to 200<span class="elsevierStyleHsp" style=""></span>mCi. The dosimetric method is more complex and involves the calculation, through <span class="elsevierStyleSup">123</span>I or <span class="elsevierStyleSup">131</span>I, of the radiation absorbed by the various organs, in order to administer the highest tumoricidal dose and avoid undesirable doses in critical organs, such as the lungs and bone marrow.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Two recent randomised clinical trials have compared the RIA success rates after the administration of 30 and 100<span class="elsevierStyleHsp" style=""></span>mCi, with levothyroxine withdrawal and rhTSH stimulation procedures in low and intermediate risk patients.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">13,14</span></a> The results, which were very similar, showed that the ablation success rate did not change when using low or high doses of RI, nor when increasing endogenous or exogenous TSH (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Fewer adverse events were observed after the administration of 30<span class="elsevierStyleHsp" style=""></span>mCi of RI and after the preparation with rhTSH.<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">13,14</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">As a corroboration of these findings, 2 recent meta-analyses, one with 7 randomised trials including 1772 patients<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> and another one with 9 randomised trials including 2,569 patients,<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a> demonstrate that there are no significant differences as to the success of percentages of ablation nor as to the scores of the test on quality of life with activities of 30, 50 and 100<span class="elsevierStyleHsp" style=""></span>mCi. Moreover, data showed that the lowest dose involved reduced adverse events and admission times.<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The rate of long-term recurrence also seems similar when levothyroxine or rhTSH withdrawal is implemented. A recent study examined, during a 10-year follow-up, 159 patients with DTC, most of whom were low or intermediate-risk patients, who received RIA with low activity (30<span class="elsevierStyleHsp" style=""></span>mCi) and were prepared with rhTSH or withdrawal. The authors found no significant differences among these groups regarding the rates of remission or recurrence.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">19</span></a></p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ablation benefits</span><p id="par0065" class="elsevierStylePara elsevierViewall">One of the advantages of RIA is that it allows the conduction of a full body scan 2–5 days after the administration of RI, which is a high sensitivity test for the detection of disease sites outside the thyroid bed. Besides, RIA facilitates the patient follow-up and the detection of recurrent disease through the determination of Tg or the conduction of diagnostic scans with RI.<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> After the thyroidectomy plus RIA, the detectable serum Tg results from tumour cells, which is an unquestionable advantage offered by this procedure.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">It also seems evident that RIA improves survival and reduces the recurrence in high-risk patients, but this is not so evident in low-risk patients. In fact, the initial study conducted by Mazzaferri and Jhiang<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">20</span></a> showed, in a group of 1,355 patients with DTC, with a follow-up median of 15.7 years, that the rates of recurrence and specific mortality were about 3 times lower in patients who received RI after surgery than those who did not. However, more recent studies have not been able to confirm these initial results, especially when analysed in low or intermediate-risk patients.<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The broad meta-analysis conducted by Sawka et al.,<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">22</span></a> including 28 observational studies with more than 5000 patients, could not confirm the efficacy of RI regarding the reduction of the rate of recurrence or specific mortality in low-risk patients. A prospective study conducted by the <span class="elsevierStyleItalic">National Thyroid Cancer Treatment Cooperative Group</span> in 2936 patients in stage <span class="elsevierStyleSmallCaps">i</span> did not show any significant benefit from RIA regarding overall, specific and disease-free survivals.<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">23</span></a> An extension of this study conducted with 4767 patients concluded that RIA in patients with stage <span class="elsevierStyleSmallCaps">i</span> DTC offered no survival benefits.<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">24</span></a> These studies are limited by a relatively short follow-up period (5.3 years). However, another recent observational multicentre study including 1,300 low-risk patients, with more than 10 years of follow-up, determined that the use of RI did not extend the overall or the disease-free survival in low-risk patients.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">25</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, the evidence available to date, based on observational studies, given that there are no randomised clinical trials, has shown no definite benefits from RIA regarding the reduction of the rate of recurrence or mortality in patients with low-risk DTC.<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">22–25</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Ablation risks</span><p id="par0085" class="elsevierStylePara elsevierViewall">RI is considered a safe treatment, though it has adverse events, such as those included in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>, most of which are temporary. The risk of leukaemia or other neoplasias increases especially with high-accumulated activities. Rubino et al.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">26</span></a> determined that a 100<span class="elsevierStyleHsp" style=""></span>mCi dose of RI would result in an overall increase of the risk of second neoplasia in 27% and that there was a linear dose-response relationship between RI and the appearance of tumours. In a cohort of 30,278 patients with DTC who participated in the SEER programme, after a 103-month average follow-up, there was a 20% increase of the risk of second neoplasia in patients who had received RI.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">27</span></a> Additionally, the most recent results from the SEER database show that the incidence of second neoplasia due to exposure to RI is increasing slightly in patients with low-risk thyroid cancer.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">28</span></a> Another study, conducted in 895 patients with DTC, showed that the accumulated risk of second neoplasia after 20 years was significantly higher in patients who had received RI compared to those who had not received it (13.5 versus 3.1%).<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">29</span></a> These results, combined with the lack of evidence that RI treatment improves survival in low-risk patients, show that the generalised use of RIA leads to overtreatment, followed by problems for the patient and economic costs.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Follow-up of no ablation patients</span><p id="par0090" class="elsevierStylePara elsevierViewall">The follow-up of low-risk patients may be conducted through serial determinations of Tg during the treatment with levothyroxine and cervical scans. In a group of 290 low-risk patients who did not receive RIA, 60% of them had undetectable Tg during the first year of thyroidectomy. In the rest of the patients, Tg was detectable during the first year, but it progressively and spontaneously decreased later on, so, after 5 years, 79% of the patients had undetectable Tg and 95% of them had Tg under 1<span class="elsevierStyleHsp" style=""></span>ng/ml.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">30</span></a> Only one of 290 patients had recurrence, which was associated with a gradual increase of Tg levels.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The specificity of Tg in RIA patients is reduced during the first year, but its level increases as the follow-up continues. Residual normal thyroid cells usually stabilise or reduce Tg production, unlike neoplastic cells. Therefore, the increasing or decreasing tendency of its levels is essential.<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">30,31</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The scan is important for patients both with and without RIA and it provides valuable information about the location of the disease. Several studies have demonstrated that cervical scans are more sensitive to the detection of lymphatic metastases than stimulated Tg or RI scans.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">31</span></a> Besides, they have an excellent predictive value, especially in low-risk cases. Therefore, their use is particularly useful during the first months of follow-up in low-risk patients without RIA, when serum Tg results are more difficult to interpret. A negative scan during the first months indicates an almost 100% chance of having a favourable long-term result, regardless of serum Tg.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">32</span></a> The specificity of this test may increase by conducting puncture-aspiration cytology of suspicious nodes according to the scan<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">31</span></a> and Tg measurement in needle washout fluids.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In patients with anti-Tg antibodies, follow-up must be carried out through cervical scans and diagnostic scans. However, serial antibody titres may be used as a surrogate marker of thyroid or tumour remnants. In these patients, the decrease in antibody titres is considered an indicator of recovery from the disease.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">33</span></a> Logically, diagnostic full body scans are more sensitive in patients who have received RIA. However, after a thyroidectomy conducted by expert surgeons, capture within the thyroid bed is generally low, and this level of capture does not usually prevent the visualisation of distant metastasis, if a diagnostic scan is conducted.<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Risk stratification</span><p id="par0110" class="elsevierStylePara elsevierViewall">Most DTC classified as low-risk carcinomas are not very aggressive. Some retrospective studies have demonstrated that there are, however, thyroid papillary microcarcinomas (TPMC) that may be accompanied by lymphatic metastases<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">8</span></a> or other characteristics that worsen prognosis, such as extrathyroidal extension and multifocality.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">4,35,36</span></a> In spite of that, specific mortality in these patients is still very low, with a survival rate higher than 99% after 10 and 15 years.<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">37</span></a> Therefore, when deciding whether or not to use RIA in specific patients, it is essential to assess their risk of recurrence, which may be based on various variables, including the characteristics of the tumour and the host.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Unlike what happens with papillary carcinomas larger than 1<span class="elsevierStyleHsp" style=""></span>cm, the <span class="elsevierStyleItalic">age</span> <45 years was a negative prognostic factor in patients with TPMC in one study,<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a> given that it was more commonly associated with other risk factors. Younger patients commonly have larger TPMC, extrathyroidal extension and lymphatic metastases, as well as a greater chance of recurrence in the future.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">38</span></a> The male <span class="elsevierStyleItalic">sex</span> has also been associated with a higher risk of recurrence of tumours<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">39</span></a> and lymphatic metastases.<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Some authors believe that the 1<span class="elsevierStyleHsp" style=""></span>cm limit <span class="elsevierStyleItalic">size</span> is arbitrary and that other sizes may better show if RIA is needed or not. Lee et al.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">41</span></a> showed that TPMCs ≤7<span class="elsevierStyleHsp" style=""></span>mm had a lower chance of central lymph node metastases (30.6%) than 7–10<span class="elsevierStyleHsp" style=""></span>mm carcinomas (47.8%). Extrathyroidal extension<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">35</span></a> and multifocality,<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a> as well as the presence of lymphatic metastases,<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">35,40</span></a> are also more common in 7–10<span class="elsevierStyleHsp" style=""></span>mm TPMCs.</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Multifocality</span> has also been observed in about one third of the patients with TPMC.<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">4,8,35,36,42</span></a> It is associated with larger tumours, lymphatic metastases and extrathyroidal extension. However, when all sites are <1<span class="elsevierStyleHsp" style=""></span>cm, current data shows that multifocality does not increase the risk of recurrence,<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">38</span></a> and that RIA provides no benefits regarding the prevention of recurrence.<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">42</span></a> Therefore, multifocality by itself should not be considered a risk factor for RIA, provided that all sites are no larger than 10<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">compromise of lymph nodes</span> has been estimated in 27–42% of TPMC cases in more recent studies,<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">4,35,36,40</span></a> but this figure may be underestimated, since lymphadenectomy is not generally conducted when an incidental microcarcinoma is found. Lymphatic metastases are more common in male patients, in young patients (≤45 years) and in multifocal TPMC cases, with extrathyroidal extension and larger than 6<span class="elsevierStyleHsp" style=""></span>mm.<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">40,40</span></a> The presence of lymph node metastases upon diagnosis has also been associated with the recurrence of the disease during follow-up in a study including 445 patients with TPMC, with a 5.3-year average follow-up,<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">35</span></a> and in another study involving 231 patients with TPMC, with a 12-year follow-up.<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">38</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">histological variants</span> that are considered to be high risk are tall cells, columnar cells, and diffuse sclerosing cells for papillary carcinoma, and highly invasive cells and poorly differentiated cells for follicular carcinoma. Some studies,<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">43</span></a> though not all of them,<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a> have demonstrated that the follicular variant of papillary carcinoma is less associated with lymphatic metastases.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Recently, studies have demonstrated that the <span class="elsevierStyleItalic">BRAF</span><span class="elsevierStyleSup">V600E</span> mutation is a marker that could improve the prognostic stratification in patients with papillary carcinoma. Some studies,<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">44,45</span></a> though not all of them,<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">46,47</span></a> have associated the presence of the <span class="elsevierStyleItalic">BRAF</span><span class="elsevierStyleSup">V600E</span> mutation with lymphatic metastases, extrathyroidal extension and recurrence of the disease and, in general terms, with a more aggressive biological behaviour, even in low-risk patients.</p><p id="par0145" class="elsevierStylePara elsevierViewall">According to some authors, in patients with this mutation, RIA seems advisable to increase the reliability of serum Tg during follow-up, while mutation negativity would render the RIA unnecessary in these low-risk patients, given their high negative predictive level.<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">45</span></a> However, the <span class="elsevierStyleItalic">BRAF</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">V600E</span></span> mutation has been observed in 24-63% of patients with TPMC, and it is unlikely that all of them have aggressive behaviour, so the presence of this mutation is not an absolute predictive agent; instead, it should be assessed together with other histopathologic and clinical characteristics for the stratification of risk.<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">48</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Current indications of ablation</span><p id="par0150" class="elsevierStylePara elsevierViewall">Unfortunately, there are no homogeneous indications in the clinical practice guidelines currently en force. In general, these guidelines distinguish between 3 groups of patients: a group where there is no RIA indication, another where its administration is clearly indicated and, finally, a last group where administration of RI should be considered or conducted in a selective manner (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">The European Consensus<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a> considers that there is no need for ablation in cases with low risk of recurrence and specific mortality, as with unifocal tumours ≤1<span class="elsevierStyleHsp" style=""></span>cm, without lymph node metastases or extrathyroidal extension, with favourable histology and complete surgery. Probable indication cases include those with any of the following characteristics: less than total thyroidectomy, no lymphatic dissection, age <18 years, T1 tumours >1<span class="elsevierStyleHsp" style=""></span>cm or T2 tumours (N0M0), or unfavourable histology.</p><p id="par0160" class="elsevierStylePara elsevierViewall">The ATA does not recommend the administration of RIA to patients with tumours of 1<span class="elsevierStyleHsp" style=""></span>cm or less, intrathyroidal or microscopic multifocal tumours without documented lymphatic metastases and complete surgery. Selective use is for intrathyroidal tumours of 1–2<span class="elsevierStyleHsp" style=""></span>cm, intrathyroidal T2 tumours (>2–4<span class="elsevierStyleHsp" style=""></span>cm), T3 tumours of any size with minimal extrathyroidal extension and, also, for N1 cases. The guidelines of the <span class="elsevierStyleItalic">National Comprehensive Cancer Network</span><a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">7</span></a> do not recommend RIA for unifocal or multifocal microcarcinomas in the thyroid gland and recommend a selective use in patients with tumours of 1–4<span class="elsevierStyleHsp" style=""></span>cm in the thyroid gland, with a high-risk histology, vascular invasion or cervical lymph node metastases when the combination of clinical factors indicates a significant risk of recurrence or specific mortality. Other guidelines provide recommendations very similar to those mentioned above.<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">2,16,49–52</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">All experts recommend RIA in patients with tumours of any size, with macroscopic extrathyroidal extension and distant metastasis. The European Consensus also recommends RIA in cases of incomplete tumoral resection, tumours with extrathyroidal extension (T3 or T4) and in the presence of lymph node metastases.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The lowest necessary dose must be used to achieve ablation, especially in low-risk cases.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a> The Estimabl<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">13</span></a> and HiLo<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">14</span></a> studies have shown the equivalence of 30 and 100<span class="elsevierStyleHsp" style=""></span>mCi doses of RI in low-risk patients, so we should increasingly tend to administer low doses in patients of this group who require RIA (tumours of 1–2<span class="elsevierStyleHsp" style=""></span>cm). It has also been suggested that these low doses should be selectively used in moderate-risk patients (T2, N1) and traditional doses should be used in high-risk patients (T3, T4, M1).<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a> It has been shown that the use of rhTSH increases the quality of life of patients and reduces exposure to radiation in non-thyroidal tissues, compared to the stimulation of endogenous TSH with T4 withdrawal.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion and future perspective</span><p id="par0175" class="elsevierStylePara elsevierViewall">RIA is necessary in patients with progressed, aggressive or metastatic disease, but these patients are a minority in current medical consultations. The most common are patients with small DTC and low risk of recurrence, for whom RIA should be limited. The final decision regarding the administration of RIA to low-risk patients may be complex and delicate. General practitioners must avoid unnecessary treatments in most cases, but have to indicate these for a minority of patients who really need them. In our opinion, clinical, radiologic, histologic, molecular and biochemical data must be carefully assessed before making a decision. It is advisable that physicians clearly and objectively explain to patients the advantages and disadvantages of RIA, make sure that patients understand these and take into account their preferences when making a decision.</p><p id="par0180" class="elsevierStylePara elsevierViewall">It is true that some physicians recommend RIA in low-risk patients in order to facilitate their follow-up and that some patients may feel comfortable with this approach.<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">53</span></a> In these cases, the 30<span class="elsevierStyleHsp" style=""></span>mCi dose may be appropriate, since it has an effectiveness rate similar to that achieved by higher doses. The use of rhTSH prevents the occurrence of adverse events resulting from hypothyroidism, which leads to the withdrawal of levothyroxine, which increases the quality of life of patients.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Future research must provide data from clinical trials that compare the long-term results of ablation with no ablation in a population with a considerable number of patients and appropriate follow-up in order to achieve an acceptable statistical power.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">54</span></a> In the near future, we will also have data showing if the so-called mini-activities (20<span class="elsevierStyleHsp" style=""></span>mCi) can be as effective as higher activities<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">55</span></a> and if levothyroxine micro-withdrawal techniques, together with a unique injection of rhTSH, could lead to an attractive alternative to ablation.<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">56</span></a> Computer systems that help decision makers<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">57</span></a> could be useful in clinical practice. Finally, molecular biology developments will make it possible to define, with greater safety, the biological behaviour of tumours.<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors affirm that they have no conflicts of interest regarding this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres548896" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec566611" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres548895" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec566612" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition of low-risk patient" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Basics of radioiodine ablation" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Preparation" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Dosage and activity" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Ablation benefits" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Ablation risks" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Follow-up of no ablation patients" ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Risk stratification" ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Current indications of ablation" ] 12 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion and future perspective" ] 13 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflict of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-01-06" "fechaAceptado" => "2014-01-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec566611" "palabras" => array:6 [ 0 => "Radioiodine" 1 => "Iodine-131" 2 => "Ablation" 3 => "Differentiated thyroid cancer" 4 => "Low risk" 5 => "Personalised medicine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec566612" "palabras" => array:6 [ 0 => "Radioyodo" 1 => "Yodo-131" 2 => "Ablación" 3 => "Cáncer diferenciado de tiroides" 4 => "Bajo riesgo" 5 => "Medicina personalizada" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most patients with newly diagnosed differentiated thyroid carcinoma have tumours with low risk of mortality and recurrence. Standard therapy has been total or near total thyroidectomy followed by postoperative radioiodine remnant ablation (RRA). Although RRA provides benefits, current clinical guidelines do not recommend it universally, since an increase in disease-free survival or a decrease in mortality in low risk patients has not been demonstrated so far. Advancements in our understanding of the biological behaviour of thyroid cancer have been translated into the clinic in a personalised approach to the patients based on their individual risk of recurrence and mortality. Current evidence suggests that RRA is not indicated in most low-risk patients, especially those with papillary carcinomas smaller than 1<span class="elsevierStyleHsp" style=""></span>cm, without extrathyroidal extension, unfavourable histology, lymph node involvement or distant metastases. Follow-up of these patients with serial measurements of serum thyroglobulin and neck ultrasound is adequate. Careful evaluation of all risk factors of clinical relevance will allow a more realistic assessment of each individual patient.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La mayoría de los pacientes con carcinoma diferenciado de tiroides presentan tumores de bajo riesgo de mortalidad y recidiva. El tratamiento estándar de estos tumores ha consistido en la tiroidectomía total o casi total, seguida de la ablación de los restos tiroideos con radioyodo (ARI). Aunque la ARI aporta ventajas, las actuales guías clínicas no la recomiendan de forma universal, ya que no se ha demostrado que aumente la supervivencia libre de enfermedad o reduzca la mortalidad en pacientes de bajo riesgo. Los avances en la comprensión del comportamiento biológico del cáncer de tiroides se han traducido en la clínica en una aproximación personalizada al paciente basada en su riesgo particular de recidiva y mortalidad. La evidencia actualmente disponible muestra que la ARI no está indicada en la mayoría de los pacientes de bajo riesgo, especialmente los que presentan carcinomas papilares menores de 1<span class="elsevierStyleHsp" style=""></span>cm, sin extensión extratiroidea, histología desfavorable, compromiso ganglionar ni metástasis a distancia. El seguimiento de los pacientes de bajo riesgo con determinaciones de tiroglobulina sérica y ecografías seriadas se considera suficiente. La evaluación cuidadosa de todos los factores de riesgo de relevancia clínica nos permitirá una evaluación más realista de cada paciente concreto.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Díez JJ, Grande E, Iglesias P. Ablación posquirúrgica con radioyodo en pacientes con carcinoma diferenciado de tiroides de bajo riesgo. Med Clin (Barc). 2015;144:35–41.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">AJCC/UICC: <span class="elsevierStyleItalic">American Joint Committee on Cancer/Union Internationale Contre le Cancer</span>; RIA: postoperative radioiodine ablation; ATA: <span class="elsevierStyleItalic">American Thyroid Association</span>; M0: no distant metastasis; M1: distant metastasis; N0: no lymph node metastasis; N1a: central cervical lymph node metastasis (level VI); N1b: other lymph node metastasis (levels <span class="elsevierStyleSmallCaps">I</span>–<span class="elsevierStyleSmallCaps">V</span> or <span class="elsevierStyleSmallCaps">VII</span>); T1: tumour ≤2<span class="elsevierStyleHsp" style=""></span>cm; T2: tumour >2<span class="elsevierStyleHsp" style=""></span>cm to 4<span class="elsevierStyleHsp" style=""></span>cm; T3: tumour >4<span class="elsevierStyleHsp" style=""></span>cm or minimum extrathyroidal invasion; T4a: macroscopic extrathyroidal invasion; T4b: macroscopic invasion of fascia or prevertebral vessels.</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of mortality (AJCC/UICC classification)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><45 years \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">≥45 years \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1N0M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T2N0M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1-2, N1a, M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T3, N0-1a, M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IVA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1-3, N1b,M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T4a, N0-1b, M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IVB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T4b, M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">IVC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886706.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of recurrence or persistence</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ATA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">European Consensus \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Low risk</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Very low risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Completely removed primary tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unifocal microcarcinoma (≤1<span class="elsevierStyleHsp" style=""></span>cm) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No extrathyroidal extension. No lymph node metastases. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No extrathyroidal extension. No lymphatic metastases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No distant metastases. No vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete surgery. Favourable histology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>If RIA is conducted: no capture outside the thyroid bed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Intermediate risk</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Low risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Microscopic extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No local or distant metastases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cervical lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No tumoral invasion of tissues or locoregional structures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aggressive histology<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No aggressive histology or vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extrathyroidal capture after RIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">High risk</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">High risk</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Macroscopic extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Less than total thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Incomplete tumoral resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumoral invasion of tissues or locoregional structures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distant metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cervical lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inadequately high or increasing thyroglobulin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distant metastases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aggressive histology or vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886707.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Aggressive histology: variant of tall cells, columnar cells, diffuse sclerosing cells (papillary carcinoma); highly-invasive and poorly differentiated (follicular carcinoma). Summarised and adapted from Pacini et al.,<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a> Cooper et al.<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a> and <span class="elsevierStyleItalic">American Joint Committee on Cancer</span>.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">9</span></a></p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Stratification of the risk of mortality and risk of recurrence or persistence in patients with differentiated thyroid carcinoma.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">RIA: postoperative radioiodine ablation; DTC: differentiated thyroid carcinoma; Tg: thyroglobulin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Objective \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Additional benefit \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Remove any normal thyroid tissue remnants left after the surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Increase the specificity of serum Tg (facilitate follow-up) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Destroy small hidden sites of DTC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduce the rate of recurrence (adjuvant treatment) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Allow the conduction of a full body scan after RIA with high sensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Detect locoregional and distant diseases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886705.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Objectives of radioiodine ablation in patients with low-risk differentiated thyroid carcinoma.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">rhTSH: recombinant human thyrotropin; Tg: serum thyroglobulin.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Summarised and adapted from Schlumberger et al.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">13</span></a> and Mallick et al.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">14</span></a></p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Estimabl<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">13</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HiLo<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">54</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patients (total/assessable) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">752/684 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">438/421 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Characteristics of the patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥18 years old; 78% female patients; 9.4% lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16–80 years old; 74% female patients; 16% lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Characteristics of the tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1/any N or T2N0; no metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1 to T3/any N/M0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ablation assessment (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Definition of ablation success \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal cervical scan and Tg stimulated with rhTSH ≤1<span class="elsevierStyleHsp" style=""></span>ng/ml (or negative scan in patients with anti-Tg antibodies) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tg <2<span class="elsevierStyleHsp" style=""></span>ng/ml and negative scan \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886702.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Ablation preparation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Withdrawal of levothyroxine</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">rhTSH</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Withdrawal of levothyroxine</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">rhTSH</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Administered activity (mCi) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ablation success (number/total) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">156/170 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">156/166 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160/177 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">159/171 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91/106 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92/105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91/108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92/102 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ablation success (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">87.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886701.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Success of postoperative radioiodine ablation in patients with differentiated thyroid carcinoma according to the results of 2 recently published randomised, Phase III clinical trials.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Risks or disadvantages \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Possibility of scan after the ablation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sialadenitis, xerostomia, dental caries \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Facilitation of follow-up and detection of recurrence or persistence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nasolacrimal obstruction, epiphora \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Improvements in survival of high-risk patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Radiation thyroiditis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Possible reduction of the risk of recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gonadal dysfunction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Risk of second neoplasia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886703.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Advantages and disadvantages of postoperative radioiodine ablation.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summarised and adapted from Pacini et al.,<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a> Cooper et al.,<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">6</span></a> Tuttle et al.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">7</span></a> and Perros.<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">16</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommended use or definite indication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Selective use or probable indication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Not recommended use (no indication) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">American Thyroid Association</span>, 2009</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Macroscopic extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumours from 1 to 4<span class="elsevierStyleHsp" style=""></span>cm without extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumours ≤1<span class="elsevierStyleHsp" style=""></span>cm, unifocal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Known distant metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumours with minimum extrathyroidal extension (T3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multifocal tumour with all sites ≤1<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumours >4<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymph node metastases (N1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No documented lymph node metastases (N0, Nx) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High-risk histologic types \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No high-risk characteristics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">National Comprehensive Cancer Network, 2012</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Macroscopic extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumours from 1 to 4<span class="elsevierStyleHsp" style=""></span>cm, intrathyroidal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unifocal or multifocal microcarcinoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumours >4<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">High-risk histologic types \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intrathyroidal \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distant metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vascular invasion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tg <1<span class="elsevierStyleHsp" style=""></span>ng/ml with negative anti-Tg antibodies \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cervical lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative radioiodine scan \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Combination of risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">European Consensus, 2006</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distant metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Less than total thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Incomplete tumoral resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No lymph node dissection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favourable histology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete resection, but high risk of recurrence or mortality: extrathyroidal extension (T3 or T4) or lymph node metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Age <18 years. T1 >1<span class="elsevierStyleHsp" style=""></span>cm and T2, N0, M0. Unfavourable histology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unifocal tumour ≤1<span class="elsevierStyleHsp" style=""></span>cm, N0, M0. No extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">British Thyroid Association/Royal College of Physicians</span>, 2007</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Distant metastases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Less than total thyroidectomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Complete surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Incomplete tumoral resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lymph node status not assessed in surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Favourable histology \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complete tumour resection, but high risk of recurrence or mortality: extrathyroidal extension beyond the capsule or >10 lymph node metastases and >3 lymph node metastases with extracapsular extension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumour size >1<span class="elsevierStyleHsp" style=""></span>cm and <4<span class="elsevierStyleHsp" style=""></span>cm. Tumour <1<span class="elsevierStyleHsp" style=""></span>cm with unfavourable histology. Multifocal tumours <1<span class="elsevierStyleHsp" style=""></span>cm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Unifocal tumour ≤1<span class="elsevierStyleHsp" style=""></span>cm, N0, M0 or minimally invasive follicular carcinoma without vascular invasion and <2<span class="elsevierStyleHsp" style=""></span>cm. No extrathyroidal extension \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab886704.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Current recommendations for postoperative radioiodine ablation in patients with differentiated thyroid carcinoma.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:57 [ 0 => array:3 [ "identificador" => "bib0290" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-surgical use of radioiodine (<span class="elsevierStyleSup">131</span>I) in patients with papillary and follicular thyroid cancer and the issue of remnant ablation: a consensus report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Pacini" 1 => "M. 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