Abstract
Background/Aim: Radioactive iodine (RAI) treatment is a cornerstone of treatment of differentiated thyroid carcinoma. Although serious RAI-related complications are uncommon, there have been reports of airway emergencies. Here, a life-threatening airway complication after RAI treatment is reported and previously reported cases are reviewed. Case Report: A 79-year old man with Hürthle cell carcinoma and a remnant thyroid lobe after surgery developed an edema compromising the airway two days after receiving radioactive iodine treatment. An emergency awake intubation and tracheostomy were performed. He could be successfully de-cannulated 17 days later with no long-term complications. Conclusion: Although rare, life-threatening airway complications after radioactive iodine treatment, especially with high dose treatment in patients with remaining thyroid tissue, can occur and these patients should be supervised where these complications can be managed.
Together with surgery and external radiotherapy, radioactive iodine therapy (RAI) with the iodine isotope 131 (131I) is a cornerstone in the treatment of differentiated thyroid carcinoma (1, 2). The aim of RAI treatment is ablation of all thyroid tissue remaining after surgery to achieve complete remission. The treatment is usually safe, but airway complications have been reported previously (Table I) (3-6). Here, a life-threatening airway complication after high-dose RAI in a patient with Hürthle cell carcinoma is reported. A 79-year-old man with a medical history of glaucoma and colon carcinoma in remission after surgery presented with a rapidly growing lump in the right side of the neck. Cytology indicated a thyroid neoplasia and a hemi-thyroidectomy was performed. Intraoperatively it was discovered that the tumor encased the right recurrent nerve that had to be resected. The histological diagnosis was Hürthle cell carcinoma with positive surgical margins and microvascular invasion. At a multidisciplinary conference, it was decided to recommend high-dose RAI treatment since the patient refused further surgery with risk of a bilateral recurrent nerve paralysis and external radiotherapy. A 131I -dose of 7.4 GBq was administered, and the patient was then admitted to the ward for supervision. Twenty-seven hours later, he developed a rapidly onset and progressive dyspnea with diffuse swelling of the neck. Despite administration of corticosteroids the symptoms worsened. A laryngoscopy revealed a supraglottic edema that severely restricted the airway. The patient was immediately taken to the operating room where a successful awake intubation and then a tracheostomy were performed. A post-operative computed tomography (CT)-scan showed diffuse transglottic swelling obstructing the airway (Figure 1). The TSH and T4 levels were normal at 1.3 mIU/l and 14.0 pmol/l, respectively. The C-reactive protein was slightly elevated and peaked at 50 mg/l two days later; the leukocytes were only mildly elevated. The edema slowly subsided with a postoperative administration of per oral corticosteroids and the antihistamine cetirizin. The patient was successfully de-cannulated 17 days later and discharged without any further complications with a TSH-suppression dose of levothyroxine. He died five years later with no signs of recurrence.
Previously reported airway emergencies in patients treated with radioactive iodine.
Computed tomography scan of the neck in the patient two days after 131I treatment showing diffuse edema obstructing the airway above the tracheostomy.
Discussion
RAI is an essential modality in the treatment of differentiated thyroid carcinoma (1, 2). Although serious side effects are rare, here a life-threatening airway complication is reported. There have been previous reports of airway complications related to RAI treatment (Table I) (3-6). In the twelve patients reported in previous case-reports and case-series, ten had remnant thyroid tissue at the time of RIA (Table I). Eleven of the twelve patients were successfully managed with medical treatment (antihistamine and corticosteroids) alone. Furthermore, the symptoms in all twelve patients were reported within the first three days after 131I administration (Table I). In one of the cases reported by Kinuya et al., both intubation and a tracheostomy were required (4). Like our patient, she had a vocal cord paralysis after surgery that could have contributed to the need for the emergency airway management. Two other factors probably contributed to the rapid onset and prolonged course in our patient: The remnant left thyroid lobe and the high dose of 131I. Immunological reactions to deteriorating thyroid tissue have been proposed as a possible mechanism in patients with RAI-associated airway complications (3). It is the authors’ opinion that serious airway complications in patients treated with RAI, although uncommon, should be anticipated. Especially patients undergoing high-dose RAI with remaining thyroid tissue and/or vocal cord paralysis should be monitored in a ward with physicians and health care workers capable of managing these complications, especially during the first three days after administration.
Acknowledgements
We thank Dr. Åke Randestad for reminding the authors about the case.
Footnotes
Authors’ Contributions
Fredrik Landström was the principal author. Jana Sandberg and Johan Reizenstein provided valuable oncological perspectives and were co-authors.
Conflicts of Interest
The Authors have no conflicts of interest to disclose in relation to this study.
- Received January 23, 2023.
- Revision received February 2, 2023.
- Accepted February 3, 2023.
- Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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