BACKGROUND
Most patients with thyroid cancer do well as we have very effective treatments. Surgery often is the only treatment needed. If the patient has persistent cancer or is at high risk of the cancer returning, radioactive iodine therapy is effective at killing thyroid cancer cells left behind after surgery or when the cancer moves outside of the neck. However, in some patients, the thyroid cancer is resistant to these 2 highly effective treatments and chemotherapy drugs are needed.

Lenvatinib is a chemotherapy drug that is effective against advanced thyroid cancer that is not responsive to other treatments. It has been shown to improve survival in these patients with advanced thyroid cancer. Patients receiving this medication often develop side effects including fatigue (59%), loss of appetite (50%) and weight loss (46%). These symptoms can also be seen in patients with another endocrine disorder know as adrenal insufficiency. Adrenal insufficiency is a steroid deficiency resulting from reduced adrenal steroid synthesis. The diagnosis of adrenal insufficiency is commonly delayed because of the nonspecific nature of its associated symptoms. Early identification and treatment are of high importance, since untreated adrenal insufficiency can be deadly. A prior study described adrenal insufficiency in 4 of 7 patients treated with lenvatinib. This study describes a patient with adrenal insufficiency while taking lenvatinib and discusses the natural history of adrenal insufficiency in patients undergoing this treatment.

THE FULL ARTICLE TITLE
Monti S et al 2022 Cortisol deficiency in lenvatinib treatment of thyroid cancer: An underestimated common adverse event. Thyroid 32:46–53. PMID: 34663079

SUMMARY OF THE STUDY
Patients with advanced thyroid cancer were studied. The study was conducted in Italy and involved a review of the medical records. The patients in the study had received lenvatinib for at least a period of 6 months between June 2017 and November 2019. Adrenal gland function was assessed before starting therapy and every 3 months with a test called the ACTH stimulation test. Patients who were diagnosed with an insufficiency of the adrenal gland were started on treatment with steroids.

It was shown based on laboratory testing that about half the patients receiving the medication Lenvatinib were diagnosed with adrenal insufficiency. All patients who developed this side effect were above the age of 60 years. The patients who were diagnosed with this condition was started on steroid therapy. A majority of them reported improvement in symptoms of fatigue.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study shows us that it would be important to look at the diagnosis of adrenal insufficiency in patients were experiencing symptoms such as fatigue who are being treated with chemotherapy. If diagnosed with adrenal insufficiency, treatment with steroids may help reduce symptoms from this condition.

— Vibhavasu Sharma, MD, FACE

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