1277
Original Article
Complications of Radioactive Iodine
Treatment of Thyroid Carcinoma
Stephanie L. Lee, MD, PhD, Boston, Massachusetts
Key Words
Thyroid carcinoma, complications, radioactive iodine, radioiodine,
sialoadenitis, second primary malignancy
Abstract
Radioactive iodine (RAI) in the form of 131I has been used to treat
thyroid cancer since 1946. RAI is used after thyroidectomy to ab-
late the residual normal thyroid remnant, as adjuvant therapy, and
to treat thyroid cancer metastases. Although the benefits of us-
ing RAI in low-risk patients with thyroid cancer are debated, it is
frequently used in most patients with thyroid cancer and is clearly
associated with acute and long-term risks and side effects. Acute
risks associated with RAI therapy include nausea and vomiting,
ageusia (loss of taste), salivary gland swelling, and pain. Longer-
term complications include recurrent sialoadenitis associated with
xerostomia, mouth pain, dental caries, pulmonary fibrosis, naso-
lacrimal outflow obstruction, and second primary malignancies.
This article summarizes the common complications of RAI and
methods to prevent and manage these complications. (JNCCN
2010;8:1277–1287)
Medscape: Continuing Medical
Education Online
Accreditation Statement
This activity has been planned and implemented in accordance
with the Essential Areas and policies of the Accreditation Coun-
From Boston University School of Medicine, and the Thyroid Health
Center, Boston Medical Center, Boston, Massachusetts.
Submitted July 28, 2010; accepted for publication on October 11, 2010.
Correspondence: Stephanie L. Lee, MD, PhD, Boston Medical Center, 88
East Newton Street, Endocrinology Evans-201, Boston, MA 02118.
E-mail: stlee@bmc.org
EDITOR
Kerrin M. Green, MA, Assistant Managing Editor, Journal of the
National Comprehensive Cancer Network
Disclosure: Kerrin M. Green, MA, has disclosed no relevant financial
relationships.
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
cil for Continuing Medical Education through the joint sponsor-
ship of Medscape, LLC and JNCCN – The Journal of the National
Comprehensive Cancer Network. Medscape, LLC is accredited by
the ACCME to provide continuing medical education for physicians.
Medscape, LLC designates this educational activity for a maximum
of 0.75 AMA PRA Category 1 Credits™. Physicians should only
claim credit commensurate with the extent of their participation
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CME activity: (1) review the learning objectives and author disclo-
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jnccn; (4) view/print certificate.
Learning Objectives
Upon completion of this activity, participants will be able to:
• Examine common acute and long-term adverse events as-
sociated with radioactive iodine
• Identify and construct effective management plans for
these complications
Radioactive iodine (RAI) in the form of 131I has been
used to treat well-differentiated thyroid cancer since
1946. The benefits and risks of 131I continue to be areas
of investigation and controversy. This article reviews
the short- and long-term risks of RAI therapy and cur-
rent recommendations to prevent and manage these
AUTHOR AND CREDENTIALS
Stephanie L. Lee, MD, PhD, Boston University School of Medicine;
Thyroid Health Center, Boston Medical Center, Boston, Massachusetts
Disclosure: Stephanie L. Lee, MD, PhD, has disclosed no relevant financial
relationships.
CME AUTHOR
Charles P. Vega, MD, Associate Professor; Residency Director, Department
of Family Medicine, University of California, Irvine
Disclosure: Charles P. Vega, MD, has disclosed no relevant financial
relationships.
1278 Original Article

Lee

complications. Complications from RAI therapy
have become more prevalent as thyroid cancer in-
cidence has risen (2.4-fold from 1973 to 20021), the
disease is being diagnosed at earlier ages, and postsur-
gical RAI therapy is now routine in some practices.2,3
Questionnaires completed by more than 200 patients
after RAI treatment suggested that immediate (< 3
months) side effects occurred in 76.8% of the pa-
tients, and 61% reported long-term (> 3 months af-
ter treatment) complaints.4 The most common side
effects included sialoadenitis in 33.0% of patients
and transient loss of taste or smell in 27.1%. Recog-
nizing the risk of RAI is important to better educate
patients about acute (Table 1) and long-term (Table
2) risk of this therapy and to manage the side effects
when they occur.
Table 1 Acute Side Effects of 131I Therapy
Gastrointestinal
Ageusia
Nausea
Vomiting (rare)
Stomatitis with ulcers (rare)
Salivary
Acute sialoadenitis with swelling and pain
Xerostomia (rare)
Neck
Radiation thyroiditis with pain and swelling
Painless swelling of the neck
Hematopoietic (usually nonclinically evident)
Anemia
Neutropenia
Thrombocytopenia
Pulmonary
Acute radiation pneumonitis (rare with diffuse
iodine-avid pulmonary metastases)
RAI therapy is given either as remnant ablation
(the most common use), adjuvant therapy, or treat-
ment of metastatic disease. Remnant ablation uses
RAI to destroy normal residual functioning thyroid
tissues with the goals of 1) increasing the sensitivity
of long-term monitoring of thyroglobulin levels, 2)
staging with posttherapy whole-body scan to detect
local and distant metastases, and 3) facilitating the
effectiveness of subsequent 131I treatments if a large
amount of remnant is present. RAI adjuvant ther-
apy uses 131I to destroy unknown microscopic thy-
roid cancer based on initial pathologic staging. RAI
treatment uses 131I to destroy known locoregional or
distant metastases to reduce recurrence and mortal-
ity or for palliation. A small fraction of patients with
differentiated thyroid cancer require multiple doses
of RAI for recurrent or persistent disease, as shown
in one study with a median follow-up of 19.3 months
in which 28% of the patients received 2 doses of RAI
and 8.8% of the patients received 3 doses.5
The radioactive decay of 131I emits gamma rays
and beta particles. The gamma rays pass though tis-
sues generally without interaction or damage to cel-
lular elements, and can be detected with a gamma
camera to allow imaging and localization of the RAI-
avid tissue for staging. Of the radiation from 131I,
94% is from beta particles (electrons), which collide
with cellular elements to cause nuclear damage. The
maximal range of a beta particle in tissue can be cal-
culated using the L’ Annunziata equation:
Range = 0.412 E (1.265–0.0954 ln E), where E is maxi-
mal energy of beta particle

Table 2 Chronic Side Effects of 131I Therapy Using this equation, the maximal range is 3.45
Salivary mm.6 Thus, the side effects of RAI can be predicted
Chronic or intermittent sialoadenitis to occur where the RAI is taken up and accumulates.
Salivary duct obstruction
Xerostomia with ulcers, Candida albicans, dental caries, The absorbed dose to an organ is estimated by this
and tooth loss medical internal radiation dose (MIRD) equation7:
Eye
Epiphora (excess tearing) D = [Ad(mCi) × 6 × Teff × UPTK%]/Vol
Pulmonary
Pulmonary fibrosis
The absorbed radiation dose to an organ is di-
Gonads
Male infertility (after multiple doses)
rectly related to the administered radioactivity (Ad),
Transient amenorrhea and oligomenorrhea but no the amount taken up by the organ (UPTK%), and
change in female fertility the length of time it remains in that organ (Teff), but
Bone marrow is inversely related to the volume of the organ (Vol).
Aplasia
Thyroid remnants, which have a high RAI uptake
Second primary malignancies
and a long effective half-life because of the RAI fixa-

© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010

Complications of Radioactive Iodine
tion onto protein, will receive a larger radiation dose
than salivary glands, which have a lower RAI uptake
and lower effective half-life because the RAI does
not accumulate in the salivary gland. Delivered ra-
diation dose to an organ can be increased through
inducing a higher uptake (i.e., TSH stimulation of
thyroid remnant and metastasis) and administering
a higher activity of radioactive material (i.e., amount
of mCi administered).
Salivary Gland Dysfunction
Sialoadenitis is a direct result of radiation injury from
active iodine uptake into the gland 20 to 100 times
that of plasma8 which can be seen on an 123I diagnos-
tic whole-body scan (Figure 1). The complications
can be divided into acute radiation sialoadenitis and
chronic sialoadenitis with/without dry mouth symp-
toms.5 In a prospective quantitative study, Spiegel et
al.9 showed a dose-dependent reduction in salivary
gland function after RAI therapy, and suggest that
greater than 500 mCi is associated with complete
salivary gland failure. Damage to the salivary glands
can be quantitated through technetium 99m uptake
by the salivary glands at 10 minutes and percent of
excretion of technetium 99m from the glands in re-
sponse to a sialogogue (lemon juice). These studies
showed a larger reduction in function of the parotid
glands than the submandibular glands.10
The incidence of acute radiation sialoadenitis
with swelling and pain is widely variable, reported in
between 12% and 67% of patients after RAI treat-
ment.11,12 The variability in complications is likely
related to the heterogeneity of the patient age, co-
A OP
P P
SM
THY
Figure 1  Whole-body scintigraphy showing 123I uptake/trapping after 24 hours into the submandibular (SM) and parotid (P) salivary
glands, thyroid remnant (thy), oropharynx (OP), and nasal-lacrimal secretions. (A) Anteroposterior view. (B) Lateral view.
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
Original Article 1279
morbid conditions, current administered dose, and
cumulative dose of 131I. One study showed that 11.5%
of patients receiving a mean dose of 100 mCi of 131I
had sialoadenitis, and 90% of the symptomatic pa-
tients had received prior 131I therapies.11 A recent
retrospective analysis by Grewal et al.13 suggested
that sialoadenitis occurs in 39% of patients in the
first year after a median dose of 141 mCi. A dose re-
sponse was seen with higher doses of 131I, resulting in
higher incidence of salivary gland swelling but not
dry mouth. Although most symptoms resolved within
a few weeks, 5% of patients were symptomatic 7 years
after therapy.13
Treatment with recombinant human TSH
(rhTSH) was shown to significantly reduce total-
body effective half-life and residence time of RAI.14
The faster whole-body clearance theoretically
should reduce the exposure of the salivary glands to
radiation and decrease the incidence of sialoadenitis.
This hypothesis has not been supported by the litera-
ture, which contains contradictory reports. Grewal
et al.13 suggested a lower incidence of sialoadenitis
after RAI therapy with thyroid hormone withdrawal
compared with rhTSH (20% vs. 10%), but Rosario
et al.15 found the opposite (26.6% vs. 80%). Siaload-
enitis can be prevented with lower activities of pre-
scribed 131I, good hydration, and use of sialogogues.
Quantitative studies have shown that radiation
within the parotid decreased rapidly after induction
of salivary gland secretion with lemon juice.16 How-
ever, based on the absorbed dose equation described
earlier, an increase in salivary flow after 131I therapy
should increase the total exposure of the salivary
gland to radiation. This was recently confirmed by
B
P
OP SM
THY
1280 Original Article
Lee
a quantitative 124I PET/CT study that showed a 28%
increase in salivary gland radiation dose in patients
instructed to induce salivary gland flow with lemon
juice immediately after a RAI therapy, compared
with those who did not.17 A retrospective, nonran-
domized study showed that sucking on 1 to 2 sour
candies every 2 to 3 hours for 5 days while awake,
starting 1 or 24 hours after RAI therapy, reduced
the incidence of sialoadenitis (63.8% vs. 36.8%;
P < .0010), ageusia or taste loss (39.0% vs. 25.6%;
P < .01), and dry mouth with or without repeated
sialoadenitis (23.8% vs. 11.2%; P < .005).18 The re-
view of the literature shows mixed response to the
use of sialogogues, but based on the current data it is
reasonable to recommend excellent hydration before
and after the administration of RAI and starting a
sialogogue such as lemon juice 24 hours after the ad-
ministration of RAI every 3 to 4 hours for 3 to 5 days.
Randomized studies showed that pretreatment
with 500 mg/m2 of an intravenous free radical scav-
enger agent, amifostine, reduced salivary gland in-
jury from RAI therapy,5,19,20 but not with a lower dose
of 300 mg/m2.21 Review of the current randomized
control studies does not support the use of amifostine
for preventing sialoadenitis and xerostomia.22
Chronic sialoadenitis for salivary duct stenosis
and sialectasia can be assessed with ultrasonography
and magnetic resonance sialography.23 Treatment of
acute and chronic sialoadenitis after RAI includes
good hydration, use of sialogogues such as lemon
juice or sour candies, and parotid massage. Patients
perform parotid massage by placing the heel of the
hand at the angle of the jaw and pushing upward
toward the zygomatic bone (cheek bone), and then
diagonally down to the angle of the mouth.24 Often
salty tasting salivary secretions can be tasted with re-
lief of obstruction. This medical management may be
effective in approximately 70% of patients. In the re-
maining patients whose obstruction is unresponsive
to medication therapy, interventional sialoendosco-
py may be effective in 50% to 84% for dilating ductal
stenosis with and without stenting or clearing mu-
cus plugs.25,26 Sialoendoscopy uses a 0.8- to 1.6-mm
diameter endoscope that can flush out mucus plugs,
place dilating stents, and grasp and remove stones
in the salivary ducts.27,28 Patients whose symptoms of
sialoadenitis are not improved after interventional
sialoendoscopy usually have a total occlusion or ste-
nosis of the duct.
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
Besides swelling and pain, long-term complica-
tions include salivary gland destruction, with reduc-
tion in saliva production, and salivary duct stric-
ture, with intermittent obstruction associated with
secondary infection and a consequent reduction of
saliva. Both the salivary gland dysfunction and duct
stricture can result in dry mouth or xerostomia.
Symptoms of xerostomia may occur after a reduction
of more than 50% of salivary flow.29 Chronic xero-
stomia causes oral burning and soreness, inability to
swallow dry food, difficulty speaking, increase in den-
tal caries, tooth loss, and Candida albicans or thrush.
Symptoms occur more often after multiple high-dose
131
I and external radiation. No studies specifically
examine xerostomia caused by RAI, and therefore
the following recommendations are derived from the
literature on treatment of xerostomia associated with
cancer therapy30 and Sjögren syndrome.31
Palliative treatments are not very effective for
relieving symptoms. Salivary substitutes and lubri-
cants prolong mucosal wetting and contain carboxy-
methylcellulose or natural mucins, but in clinical
studies these agents provide a mild subjective relief
of symptoms without a change in hyposalivation.29
Sugar-free lozenges, acidic candies, and chewing
gum may stimulate some salivaryside effects flow, but
it is transient and has not been studied systematical-
ly. Other palliative treatments have not been stud-
ied in randomized trials but are suggested for routine
management of dry mouth, such as humidifier use,
especially at night29; special-blended and moist, non-
acidic foods; avoidance of medications that promote
dry mouth, such as antihistamines, and some antihy-
pertensive agents, such as clonidine; and avoidance
of caffeine-containing or alcoholic beverages that
increase dehydration and worsen xerostomia.29
Salivary flow is stimulated by parasypathomi-
metics such as pilocarpine and cevimeline. Pilocar-
pine is a nonselective muscarinic agonist, but cev-
imeline binds with high affinity to M3 muscarinic
receptors predominately on salivary gland cells with
minimal adverse effects on cardiac and respiratory
organs. Oral formulations of these drugs improve sal-
ivary function to some extent in clinic trials but are
short-lived and usually require high doses that have
systemic side effects, including excessive sweating,
rhinitis, and urinary frequency.31 These muscarinic
receptor therapies should not be used in patients
with gastric ulcer, uncontrolled asthma, or hyper-

Complications of Radioactive Iodine
tension or who are taking β-blockers.30 Interesting
recent data,32 including randomized clinical trials of
acupuncture, suggest that those patients with some
residual salivary gland function have a significant in-
crease in unstimulated and stimulated salivary gland
flow that in some trials lasted up to 6 months.33,34
Preventive care, including frequent dental exami-
nations every 4 to 6 months, meticulous dental hy-
giene, low-sugar diet, and daily topical fluoride, is
important for all patients with xerostomia to prevent
tooth loss. It is felt that topical neutral fluoride may
be the most effective way to prevent xerostomia-re-
lated dental caries.35
Before undergoing RAI therapy for thyroid can-
cer, patients should be informed that salivary gland
damage may result and be either acute or chronic,
with symptoms of salivary gland pain, swelling, and
xerostomia that require meticulous oral hygiene and
avoidance of anticholinergic drugs and dehydration.
Stomatitis
Occasionally acute stomatitis is seen, which is
thought to be the result of mucosal radiation from
the 131I secreted into saliva. Although not docu-
mented in the literature, many experts have seen this
complication 5 to 7 days after therapy. Symptoms
can be controlled with an elixir mouthwash contain-
ing dexamethasone, viscous lidocaine, diphenhydr-
amine, and aluminum and magnesium hydroxide.8
Taste and Smell Changes
Ageusia or altered taste (dysgeusia) is thought to be
caused by radiation destruction of lingual taste buds
from the RAI secreted into saliva.5,36 When low and
high doses of 131I were compared (30 vs. 100 mCi), a
higher incidence of taste disturbance was associated
with the higher dose.37 However, a paucity of litera-
ture supports this common clinical observation. The
loss of taste may be accompanied by a metallic or
chemical taste, which usually resolves in 4 to 8 weeks.
No long-term alterations in taste have been reported.
Gastrointestinal Complications
Nausea is the most common gastrointestinal symp-
tom of RAI therapy but is rarely accompanied by
emesis.5 Studies have shown that 50% to 67% of pa-
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
Original Article 1281
tients complain of nausea starting as early as 2 hours
after treatment and lasting up to 2 days after therapy.
One study showed that a high dose (100 mCi) of 131I
was associated with more nausea than a low dose (30
mCi).37 A prospective study of patients who received
150 mCi of 131I found that 50% complained of nau-
sea. Antiemetics can be given intravenously to pa-
tients with severe symptoms to prevent emesis and
allow oral hydration. Acute radiation sickness char-
acterized by nausea, emesis, headache, and fatigue is
rare when doses are less than 200 mCi and less than
200 cGy of radiation exposure to the blood.38,39
Although no prospective studies have examined
prophylactic antinausea therapy for reducing nausea
associated with RAI, experts have suggested that an-
tinausea therapy is effective when given before, dur-
ing, or after RAI administration.40 Moderate nausea
may be treated with a highly effective antiemetic,
such as ondansetron, 8 mg, every 8 hours by mouth
for 2 doses, then 8 mg by mouth every 12 hours.
However, severe nausea with some emesis may be
treated with ondansetron, 8 mg, or 0.15 mg/kg intra-
venously twice daily, with fluid hydration to improve
the renal clearance of the RAI.
Neck Pain and Swelling
Radiation thyroiditis with swelling and thyroid pain
occurs 3 to 7 days after RAI therapy. Generally, this
risk is very low after near-total or total thyroidec-
tomy without extensive neck metastases.38 A pain-
less swelling of the neck has been described that oc-
curs within 48 hours after the RAI treatment. This
edema is believed to a hypersensitivity reaction in
the tissues surrounding the thyroid. Both painful and
painless neck swelling may be treated with cortico-
steroids, if necessary.
Nasolacrimal Symptoms
Kloos et al.41 first described bilateral nasolacrimal
duct obstruction with excessive tearing (epiphora) 4
months after a 450-mCi dose of 131I. Retrospective re-
view showed that 3% (10/390) of patients developed
watery eyes with overflow of tears 13 to 23 months after
multiple doses of 131I, with a mean cumulated 131I dose
of 467 mCi.42 The sodium iodide symporter is located
in tear ducts,43 and after RAI therapy the radioactive
tears result in ductal stricture. Epiphora is caused by
1282 Original Article
Lee
the stricture and obstruction of the tear duct, which
can be managed with dilation or stent placement,44
but complete obstruction requires surgical diversion of
the tear duct (dacryocystorhinostomy).42
Gonadal Radiation and Fertility
The gonads receive radiation from the free and io-
dinated proteins circulating in blood and from the
urinary excretion of the RAI. Gonadal exposure in
the first 3 days after RAI treatment can be reduced
with good hydration and frequent urination.
A study of men between 3 and 39 years of age
with thyroid cancer treated with RAI showed a
transient impairment of gonadal function (elevated
follicle-stimulating hormone [FSH], reduced testos-
terone) that resolved within 9 months.45 The radia-
tion dose absorbed by the testis after a single ablative
dose of radioiodine was estimated to be well below a
level that would result in permanent damage to ger-
minal epithelium, and the risk of infertility in these
patients was minimal. Patients requiring multiple
doses of RAI for metastatic thyroid cancer may be
at greater risk of gonadal damage, but no evidence of
infertility was seen in this cohort of young men after
a mean follow up of 21 years. In contrast, in an older
cohort of men (aged 17–60 years) followed up for
an average of 93.7 months, Pacini et al.46 found that
FSH became transiently elevated in 36% of men and
then generally slowly trended down toward baseline.
Patients who required multiple 131I therapies with
the highest cumulative dose for thyroid cancer were
found to have a rising FSH that eventually became
permanently elevated. Semen analysis performed in
a small number of patients showed a reduction in the
number of normokinetic sperm. A study of 493 chil-
dren born of fathers who underwent prior 131I treat-
ment with an average of 141 mCi showed no dif-
ference in adverse outcomes during pregnancy or in
children’s health compared with untreated fathers.47
In a systematic review of the literature, Sawka et al.48
found that biochemical abnormalities (elevated lu-
teinizing hormone, low testosterone) usually resolved
within 18 months after 131I treatment with less than
150 mCi, but the risk for persistent gonadal dysfunc-
tion increased after a repeated or high cumulative
dose of RAI. Although male fertility is not signifi-
cantly affected by a single lower dose of RAI, large
doses (> 100 mCi), especially if administered more
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
than once, may result in infertility in some men.46,48
RAI effects on female fertility have been ex-
amined carefully. Although transient amenorrhea
or oligomenorrhea has been reported after RAI,49–51
whether it is related to thyroid hormone withdrawal
is unclear. However, studies suggest no long-term al-
teration occurs in female fertility.51–55 Among 2673
pregnancies, Garci et al.56 found no increase in mis-
carriage within the first year after up to 100 mCi of
131
I. In addition, no differences were seen in still-
borns, preterm births, low birth weight, congenital
malformations, or death during the first year of life.
Thyroid and non-thyroid cancers were similar when
compared in children born before or after a mother’s
exposure to RAI.57 Additional small clinical obser-
vational studies confirm that female fertility, preg-
nancies, and babies’ health are not affected by prior
high-dose radioiodine treatment.52,54 Experts in the
field have suggested women wait up to 1 year before
attempting pregnancy after 131I treatment for thy-
roid cancer,52 partly because of a report of 2 infants
born with fatal congenital malformations to moth-
ers treated with RAI during pregnancy or 6 months
before conception. Early menopause has been re-
ported, with median time of menopause of 49.5
years of age in women treated with RAI compared
with a control cohort of women with goiters aged
50.0 years (P < .001).55 The risk of early menopause
was not associated with age at initial or repeat RAI
therapy, the dose of RAI, or number of doses. The
clinical significance of this observation is uncertain.
Bone Marrow Suppression
After thyroidectomy and in the absence of extensive
metastatic disease, asymptomatic transient drops in
white blood cell, red blood cell, and platelet counts
are seen with usual doses of 131I.58 After a mean dose
of 100 mCi of 131I, a recent study showed a small,
nonclinically important but statistically significant
decrease in white blood cell count and platelet count
after 1 year.59 The nadir usually occurs 5 to 9 weeks
after therapy. Benua et al.60 and Leeper61 identified
clinical features associated with serious bone mar-
row suppression, including patients who have exten-
sive bone metastases, had prior radiation therapy to
bone marrow, and RAI doses that result in whole-
body radiation exposure of greater than 200 cGy.60
An increased risk of bone marrow suppression was

Complications of Radioactive Iodine
noted in patients who received both RAI therapy
and external radiation therapy to bone metastases.62
When extensive iodine-avid metastases are found,
dosimetry must be considered to keep the radiation
exposure to the blood to less than 200 cGy.39
This threshold is met more often than clinicians
expect, as shown in a retrospective review.63 In pa-
tients with a normal creatinine treated with 200 mCi
of 131I, Tuttle et al.63 showed that this threshold was
exceeded in 8% to 15% of patients aged 70 years and
22% to 38% of patients older than 70 years. 131I ac-
tivity to be administered with dosimetry should be
carefully considered in elderly patients with exten-
sive iodine-avid metastatic disease.
Pulmonary Fibrosis
Radiation pneumonitis and pulmonary fibrosis were
early complications of large administered activi-
ties of 131I.60 Respiratory complications seem to be
avoided if the administered activity is limited so that
the whole-body retention at 48 hours is less than 80
mCi.38,64 Limiting the administered activity of 131I
with formal dosimetry studies would be reasonable
when diffuse iodine avid pulmonary metastases are
seen.39 Radiation pneumonitis can be treated with
high-dose corticosteroids, but no studies show effec-
tiveness of this treatment. Respiratory failure from
RAI-induced pulmonary fibrosis was treated with
lung transplantation in one case.65
Second Primary Malignancies
Pooled European and American databases of thyroid
cancer survivors have revealed a significant increased risk
of second primary malignancies after RAI therapy.66–71
Table 3 Risk of Second Primary Malignancies after 131I Therapy
Solid Tumors
Dose (mCi) Number of SPM/PYR Relative Risk
<5 184/29,625 1 4/2965
5–100 98/10,795 1.2
100–200 78/14,330 0.9
200–400 32/4693 1.4
> 400 12/1475 1.5
Abbreviations: PYR, number of person-years of follow-up; SPM, second primary malignancy.
Adapted from Rubino C, de Vathaire F, Dottorini ME, et al. Second primary malignancies in thyroid cancer patients. Br J Cancer
2003;89:1638–1644; with permission from Macmillian Publishers Ltd.
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
Original Article 1283
Based on these studies, the often quoted statement that
second malignancies, specifically leukemia did not oc-
cur with less than 600 mCi cumulative dose appears to
be incorrect; the risk occurs at much lower doses of RAI.
Rubino et al.66 examined the European cohort of 6841
patients with thyroid cancer who had a mean age of 44
years, a mean follow-up of 13 years, and treatment with
a mean 131I dose of 162 mCi. After a 2-year latency, 576
second primary malignancies were identified and, com-
pared with the general population, the increased risk of
second primary malignancy was 27% (95% CI, 15–40)
after RAI. Second primary malignancies associated with
131
I treatment included bone, colorectal, and salivary
gland cancers, and leukemia. The statistical increased
risk of solid tissue second primary malignancy seemed to
be dose-dependent (Table 3). Four groups have analyzed
the SEER database using slightly different inclusion cri-
teria, follow-up periods, and statistical analyses.67,69,70,72
Three of the groups reported an association between
RAI and risk for leukemia67,70,72; two groups reported an
increased risk of upper gastrointestinal cancer, including
stomach malignancies, associated with RAI therapy.67,72
Using the SEER database, Brown et al.67 ex-
amined 30,278 patients and found that 7% had a
second primary malignancy. The risk appeared in
the younger age group (25–29 years), with a short
latency period of 5 years. The SEER database ini-
tially did not record the administered activity of 131I,
and therefore a dose-response analysis with second
primary malignancies is not possible. Although in-
creased breast cancer risk was reported in survivors
of thyroid cancer, this study showed the control pa-
tients with thyroid cancer had a relative risk that was
3.9-fold greater than that in patients without thyroid
cancer, and after RAI therapy no statistically signifi-
cant additional risk for breast cancer was seen.
Leukemia
Number of SPM/PYR Relative Risk
1
3/10,795 1.4
4/19,684 2.6
– –
0/885 –
1284 Original Article
Lee
Two meta-analyses of the individual studies
have been published. Sawka et al.73 reviewed 2 stud-
ies and Subramanian et al.71 examined 13 studies
for their analyses. Sawka et al.73 confirmed the in-
creases in relative risk of second primary malignancy
in thyroid cancer survivors of 1.19 (95% CI, 1.04,
1.36; P = .010), whereas Subramanian et al.71 found
a similar increased risk of 1.20 (95% CI, 1.17, 124).
Sawka et al.71 found the risk for leukemia was sig-
nificantly increased, with a relative risk of 2.5, but
Subramanian et al. found the risk was elevated for
multiple soft tissue sites, including the gastrointesti-
nal system, salivary, bone, and leukemia.
To put this data into perspective, the original
data presented by Rubino et al.74 (Table 3) suggest
a significant risk for solid tissue malignancies may
not be present until higher doses of RAI are given,
although whether a lower dose threshold exists for
leukemia risk is unclear. Although the 2.5 relative
risk of leukemia is significant, this malignancy is
rare, and the small number of patients with leukemia
(n = 7) in this study, which involved more than 6800
patients, reflects a high increased risk. In addition,
as indicated by Schneider et al.,75 although a stati-
cally significant risk exists for all cancer combined,
the risk was not significantly elevated for any par-
ticular cancer, except for leukemia. Putting this into
context, the study by Rubino et al.74 predicts 16.2
excess stomach cancers over 20 years among 1000
people who received 162 mCi. In the author’s own
practice, it would be rare to see either a second pri-
mary malignancy or leukemia after remnant ablation
doses of 131I. Although the rarity of a second primary
malignancy makes screening for this occurrence dif-
ficult in thyroid cancer survivors treated with RAI,
the American Thyroid Association guidelines have
recommended routine age- and gender-appropriate
cancer screening.76 The benefits of RAI likely ex-
ceed the small risk for second primary malignancy
in patients with stage II thyroid carcinoma, but pa-
tients should be counseled that the risks for this oc-
currence, especially leukemia, are low but are still a
real risk associated with RAI therapy.
Conclusions
Review of the acute and chronic complications of
RAI therapy shows that it is associated with short-
and long-term side effects that interfere with and
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
disrupt patients’ lives.5 Clinicians must be more
thoughtful about the use of 131I in all patients, espe-
cially those at low-risk who may not need 131I at all or
those with non–iodine-avid disease or bulky disease
who are unlikely to benefit from 131I therapies. Low-
risk patients who require remnant ablation with 131I
should be given the lowest doses of 131I possible with
good hydration and should undergo rhTSH stimu-
lation, which results in lower whole-body radiation
from faster renal clearance compared with hypothy-
roidism.77 It is also critical for clinicians to recognize
the increased risk associated with repeat 131I treat-
ments for progressive or life-threatening disease with
high iodine uptake, including recurrent sialoadeni-
tis, xerostomia, and increased risk for second primary
malignancies. Formal dosimetry studies60 should be
considered in patients with very low lesional uptake
to determine if a therapeutic radiation dose can be
delivered to the tumor with a very high RAI uptake
to prevent excessive whole-body radiation exposure
and subsequent bone marrow and pulmonary com-
plications. These acute and long-term complications
of RAI should be carefully considered in patients
who have non–life-threatening, nonprogressive,
small-volume residual malignant disease. The acute
and chronic complications of RAI therapy may not
be justified in these patients, who are at low risk for
death from differentiated thyroid cancer.
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Complications of Radioactive Iodine
CME Activity: Complications
of Radioactive Iodine
To obtain credit, you should first read the journal article.
After reading the article, you should be able to answer
the following, related, multiple-choice questions. To com-
plete the questions and earn continuing medical educa-
tion (CME) credit, please go to www.medscapecme.com/
journal/jnccn.
Credit cannot be obtained for tests completed on pa-
per, although you may use the worksheet below to keep
a record of your answers. You must be a registered user
on Medscape.com. If you are not registered on Medscape.
com, please click on the New Users: Free Registration link
on the left hand side of the website to register.
Only one answer is correct for each question. Once
you successfully answer all post-test questions you will be
able to view and/or print your certificate. For questions re-
1. You are seeing a 33-year-old woman status-post thy-
roidectomy for thyroid cancer. She has been referred
to receive RAI therapy for thyroid remnant ablation,
and you are having a discussion regarding the risks for
RAI therapy before administration of RAI.
Which of the following adverse events is most com-
monly associated with RAI therapy and should be dis-
cussed with this patient?
A. Stomatitis
B. Thyroiditis
C. Excessive tearing due to nasolacrimal obstruction
D. Sialoadenitis
2. The patient receives RAI at a total dose of 150 mCi.
Salivary gland dysfunction develops. Which of the
following statements regarding this complication is
most accurate?
A. Sialogogues should be avoided in the first several
days after RAI therapy
B. ���������������������������������������������
Even low-dose amifostine can reduce the inci-
dence of sialoadenitis
C. ����������������������������������������������
Medical management is successful in 70% of pa-
tients with chronic sialoadenitis
Activity Evaluation
1. The activity supported the learning objectives.
Strongly Disagree Strongly Agree
1 2 3 4 5
2. The material was organized clearly for learning to oc-
cur.
Strongly Disagree Strongly Agree
1 2 3 4 5
To obtain credit, visit Medscape online at http://www.medscapecme.com/journal/jnccn.
© JNCCN–Journal of the National Comprehensive Cancer Network  |  Volume 8 Number 11  |  November 2010
Original Article 1287
garding the content of this activity, contact the accredited
provider, CME@medscape.net. For technical assistance,
contact CME@webmd.net.
American Medical Association’s Physician’s Recogni-
tion Award (AMA PRA) credits are accepted in the US
as evidence of participation in CME activities. For fur-
ther information on this award, please refer to http://www.
ama-assn.org/ama/pub/category/2922.html. The AMA has
determined that physicians not licensed in the US who
participate in this CME activity are eligible for AMA PRA
Category 1 Credits™. Through agreements that the AMA
has made with agencies in some countries, AMA PRA
credit is acceptable as evidence of participation in CME
activities. If you are not licensed in the U.S. and want to
obtain an AMA PRA CME credit, please complete the
questions online, print the certificate and present it to your
national medical association.
D. Oral treatment with parasympathomimetics does
not have systemic side effects
3. The patient also complains of some nausea immedi-
ately after RAI therapy. What should you consider in
the management of this adverse event?
A. It can last for 1 to 2 weeks
B. It is not related to the dose of RAI
C. ���������������������������������������������
Antinausea therapy is only effective when ad-
ministered before the onset of significant nausea
D. Ondansetron appears effective in the treatment
of nausea
4. Additionally it is important to discuss long-term com-
plications with patients undergoing RAI. Which of the
following statements should be part of this discussion?
A. RAI therapy should not affect her fertility in the
long term
B. Her white blood cell count may decrease, with
the nadir at 1 week after RAI therapy
C. Leukemia does not occur after RAI at doses less
than 600 mCi
D. RAI therapy is not associated with a higher risk
for solid tumors
3. The content learned from this activity will
impact my practice.
Strongly Disagree Strongly Agree
1 2 3 4 5
4. The activity was presented objectively and free of
commercial bias.
Strongly Disagree Strongly Agree
1 2 3 4 5