Metastatic differentiated thyroid carcinoma which is not responding to radioactive iodine therapy shows very unfavorable prognosis results in frequent recurrence. Administration of Multikinase inhibitors in this patient may give some benefit to hinder the progression of the disease process, but actually less effective on overall disease free survival. Different research works give us an idea regarding the contribution of BRAF/MEK inhibitor to suppress the disease progression in such recurrent cases where genetic mutation is noted and radio iodine is refractory. These oral anticancer drugs have promising effect in redifferentiation of BRAF positive Radio iodine refractory metastatic differentiated & also some undifferentiated or anaplastic carcinoma. Different drugs are available like Debrafenib, Trametinib, Lenvatinib, Cabozatinib etc. In our case we focus on the effect of Cabozatinib and Lenvatinib on BRAF mutated Radioiodine refractory recurrent Metastatic Papillary Carcinoma Thyroid.

A 65 years old male patient reported to Otolaryngology department for a painless growing mass on in front of the neck. Initial investigations showed a solid mass which is confirmed as Papillary Carcinoma Thyroid by FNAC. Initial CT imaging noticed multiple subcentrimetric neck nodal involvement. He underwent Total thyroidectomy with central Compartment clearance with selective neck dissection. Initial staging was stage-III (T3N1MX). After operation he received radio iodine ablation therapy 150 mci. Initially after treatment patient was symptom free and all the tumor markers were initially within normal limit. Throughout the disease process his serum Thyroglobulin level & TSH Level were within normal limit. RAI-131 whole body scan resembled no significant uptake of RAI. But patient represent with positive neck node after one year and neck nodes were positive for metastatic Papillary Carcinoma. FDG-PET (Positron emission tomography) was then performed where recurrent metastatic disease was noted with hyper metabolism in the both sided cervical lymph nodes and also some nodules in lung. Then patient again went for surgery &post operative RAI therapy. But unfortunately again recurrence occurred after a small period of time. Patient presented with neck nodal enlargement & he went for selective neck dissection for 2 consecutive times but tumor was so aggressive which results in frequent recurrence despite of expert hand surgery and post operative radioiodine therapy. Tumor was then classified as refractory case of radioiodine. Then Molecular testing was done and came to know about BRAF(V600E) gene mutation. Initially patient was treated with Lenvatinib to hinder the disease process. Subsequently patient had received 3rd dose of radio iodine therapy. But in course of treatment with Lenvatinib patient was again presented with neck nodal recurrence and also patient was hypertensive due to the adverse effects of Lenvatinib. Again surgical treatment was underwent but patient became positive unfortunately with in very short period of time. Then finally treatment starts with Cabozatinib which shows progressive regression of the neck nodes despite some adverse effects. Aggressiveness of the disease process also reduced with the medicine. By representing the case we tried to focus on alternatives way to treat aggressive refractory case of thyroid carcinoma by oral anticancer drugs like Cabozatnib

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