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Massimino M, Podda M, Gandola L, Pignoli E, Seregni E, Morosi C, Spreafico F, Ferrari A, Pecori E, Terenziani M. Long-term results of suppressing thyroid-stimulating hormone during radiotherapy to prevent primary hypothyroidism in medulloblastoma/PNET and Hodgkin lymphoma: a prospective cohort study. Front Med 2020; 15:101-107. [PMID: 32794013 DOI: 10.1007/s11684-020-0752-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/14/2020] [Indexed: 10/23/2022]
Abstract
Primary hypothyroidism commonly occurs after radiotherapy (RT), and coincides with increased circulating thyroid-stimulating hormone (TSH) levels.We tested therefore the protective effect of suppressing TSH with L-thyroxine during RT for medulloblastoma/PNET and Hodgkin lymphoma (HL) in a prospective cohort study. From1998 to 2001, a total of 37 euthyroid children with medulloblastoma/PNET plus 14 with HL, scheduled for craniospinal irradiation and mediastinum/neck radiotherapy, respectively, underwent thyroid ultrasound and free triiodothyronine (FT3), free thyroxine (FT4), and TSH evaluation at the beginning and end of craniospinal iiradiation. From 14 days before and up to the end of radiotherapy, patients were administered L-thyroxine checking every 3 days TSH to ensure a value < 0.3 μIU/mL. During follow-up, blood tests and ultrasound were repeated; primary hypothyroidism was considered an increased TSH level greater than normal range. Twenty-two/37 patients with medulloblastoma/PNET and all the 14 patients with HL were alive after a median 231 months from radiotherapy with 7/22 and 8/14 having correctly reached TSH levels < 0.3 μIU/mL and well matched for other variables. Twenty years on, hypothyroidism-free survival rates differed significantly, being 60% ± 15% and 15.6% ± 8.2% in TSH-suppressed vs. not-TSH suppressed patients, respectively (P = 0.001). These findings suggest that hypothyroidism could be durably prevented in two populations at risk of late RT sequelae, but it should be confirmed in a larger cohort.
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Affiliation(s)
- Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy.
| | - Marta Podda
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Ettore Seregni
- Department of Nuclear Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Filippo Spreafico
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Monica Terenziani
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
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Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocr Rev 2019; 40:711-767. [PMID: 30476004 DOI: 10.1210/er.2018-00092] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.
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Affiliation(s)
- Judith Gebauer
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom.,Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Thorsten Langer
- Division of Pediatric Hematology and Oncology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - Christian Denzer
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetes, Ulm University Medical Center, Ulm, Germany
| | - Georg Brabant
- Experimental and Clinical Endocrinology, University Hospital of Schleswig-Holstein, Campus Luebeck, Luebeck, Germany.,Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, United Kingdom
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Tonorezos ES, Barnea D, Moskowitz CS, Chou JF, Sklar CA, Elkin EB, Wong RJ, Li D, Tuttle RM, Korenstein D, Wolden SL, Oeffinger KC. Screening for thyroid cancer in survivors of childhood and young adult cancer treated with neck radiation. J Cancer Surviv 2017; 11:302-308. [PMID: 28028762 PMCID: PMC5527324 DOI: 10.1007/s11764-016-0588-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 12/04/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND The optimal method of screening for thyroid cancer in survivors of childhood and young adult cancer exposed to neck radiation remains controversial. Outcome data for a physical exam-based screening approach are lacking. METHODS We conducted a retrospective review of adult survivors of childhood and young adult cancer with a history of neck radiation followed in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering between November 2005 and August 2014. Eligible patients underwent a physical exam of the thyroid and were followed for at least 1 year afterwards. Ineligible patients were those with prior diagnosis of benign or malignant thyroid nodules. RESULTS During a median follow-up of 3.1 years (range 0-9.4 years), 106 ultrasounds and 2277 physical exams were performed among 585 patients. Forty survivors had an abnormal thyroid physical exam median of 21 years from radiotherapy; 50% of those with an abnormal exam were survivors of Hodgkin lymphoma, 60% had radiation at ages 10-19, and 53% were female. Ultimately, 24 underwent fine needle aspiration (FNA). Surgery revealed papillary carcinoma in seven survivors; six are currently free of disease and one with active disease is undergoing watchful waiting. Among those with one or more annual visits, representing 1732 person-years of follow-up, no cases of thyroid cancer were diagnosed within a year of normal physical exam. CONCLUSIONS These findings support the application of annual physical exam without routine ultrasound for thyroid cancer screening among survivors with a history of neck radiation. IMPLICATIONS FOR CANCER SURVIVORS Survivors with a history of neck radiation may not require routine thyroid ultrasound for thyroid cancer screening. Among adult survivors of childhood and young adult cancer with a history of radiation therapy to the neck, annual physical exam is an acceptable thyroid cancer screening strategy.
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Affiliation(s)
- Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Dana Barnea
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chaya S Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanne F Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elena B Elkin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard J Wong
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Duan Li
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R Michael Tuttle
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C Oeffinger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Lollert A, Gies C, Laudemann K, Faber J, Jacob-Heutmann D, König J, Düber C, Staatz G. Ultrasound Evaluation of Thyroid Gland Pathologies After Radiation Therapy and Chemotherapy to Treat Malignancy During Childhood. Int J Radiat Oncol Biol Phys 2015; 94:139-146. [PMID: 26545453 DOI: 10.1016/j.ijrobp.2015.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/01/2015] [Accepted: 09/14/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to evaluate correlations between treatment of malignancy by radiation therapy during childhood and the occurrence of thyroid gland pathologies detected by ultrasonography in follow-up examinations. METHODS AND MATERIALS Reductions of thyroid gland volume below 2 standard deviations of the weight-specific mean value, occurrence of ultrasonographically detectable thyroid gland pathologies, and hypothyroidism were retrospectively assessed in 103 children and adolescents 7 months to 20 years of age (median: 7 years of age) at baseline (1997-2013) treated with chemoradiation therapy (with the thyroid gland dose assessable) or with chemotherapy alone and followed by ultrasonography and laboratory examinations through 2014 (median follow-up time: 48 months). RESULTS A relevant reduction of thyroid gland volume was significantly correlated with thyroid gland dose in univariate (P<.001) and multivariate analyses for doses above 2 Gy. Odds ratios were 3.1 (95% confidence interval: 1.02-9.2; P=.046) for medium doses (2-25 Gy) and 14.8 (95% confidence interval: 1.4-160; P=.027) for high doses (>25 Gy). Thyroid gland dose was significantly higher in patients with thyroid gland pathologies during follow-up (P=.03). Univariate analysis revealed significant correlations between hypothyroidism and thyroid gland dose (P<.001). CONCLUSIONS Ultrasonographically detectable changes, that is, volume reductions, pathologies, and hypothyroidism, after malignancy treatment during childhood are associated with thyroid gland dose. Both ultrasonography and laboratory follow-up examinations should be performed regularly after tumor therapy during childhood, especially if the treatment included radiation therapy.
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Affiliation(s)
- André Lollert
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Christina Gies
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Katharina Laudemann
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jörg Faber
- Department of Pediatrics and Adolescent Medicine, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Dorothee Jacob-Heutmann
- Department of Radio-oncology and Radiotherapy, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Jochem König
- Institute for Medical Biostatistics, Epidemiology and Informatics, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Gundula Staatz
- Department of Diagnostic and Interventional Radiology, Section of Pediatric Radiology, Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Thyroid carcinoma after treatment for malignancies in childhood and adolescence: from diagnosis through follow-up. Med Oncol 2014; 31:121. [DOI: 10.1007/s12032-014-0121-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 07/03/2014] [Indexed: 12/17/2022]
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Wein RO. Acquired disorders of the thyroid following treatment for head and neck cancer. Expert Rev Endocrinol Metab 2013; 8:461-467. [PMID: 30754189 DOI: 10.1586/17446651.2013.827396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The multimodality management of head and neck cancer routinely utilizes radiation therapy in treatment. The hypothalamus, pituitary and thyroid gland may be included within treatment fields. The incidence of human papilloma virus-associated oropharyngeal carcinoma has seen a dramatic increase over the last 3 decades. Current guidelines for the long-term aftercare assessment advocate only for thyroid-stimulating hormone levels every 6-12 months after baseline posttreatment imaging. With a growing population of younger patients with a favorable prognosis exposed to therapeutic radiation therapy, it is anticipated that incidence of thyroid-associated complications, such as hypothyroidism and thyroid cancer, could increase significantly over time. Constructing a strategy for the long-term reassessment of these patients beyond existing guidelines may be necessary.
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Affiliation(s)
- Richard O Wein
- a Department of Otolaryngology-Head & Neck Surgery, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
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Bonato CC, Elnecave RH. [Thyroid disorders associated with external radiation in children and adolescents]. ACTA ACUST UNITED AC 2012; 55:359-66. [PMID: 22011852 DOI: 10.1590/s0004-27302011000600002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 08/23/2011] [Indexed: 12/12/2022]
Abstract
The effects of ionizing radiation on the thyroid have been studied for several decades, and nuclear accidents are the major source of information about the subject. There is an association of hypothyroidism, hyperthyroidism, thyroid nodules and cancer with radiation, but the threshold dose, mechanism of injury, and some risk factors have not been fully established. Children are more susceptible to thyroid injury caused by radiation and require prolonged follow-up after exposure. This issue is especially relevant nowadays, since a large number of people treated with radiation for childhood cancer survive and may have sequelae. Diagnostic radiology tests also represent a source of exposure to radiation in the pediatric population. In this review, we analyze different clinical and pathological changes, and the mechanisms of thyroid lesions caused by radiotherapy and computed tomography in children and adolescents. It is important to understand these data for prevention, early detection, and treatment of thyroid dysfunction.
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Affiliation(s)
- Cassiane Cardoso Bonato
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Massimino M, Gandola L, Pignoli E, Seregni E, Marchianò A, Pecori E, Catania S, Cefalo G. TSH suppression as a possible means of protection against hypothyroidism after irradiation for childhood Hodgkins lymphoma. Pediatr Blood Cancer 2011; 57:166-8. [PMID: 21557462 DOI: 10.1002/pbc.22915] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Accepted: 10/15/2010] [Indexed: 11/10/2022]
Abstract
Hypothyroidism remains a common late effect after irradiation of the neck/mediastinum for Hodgkins lymphoma (HL). We evaluated the protective effect of TSH suppression during neck/mediastinum irradiation. From 1998 to 2001, 14 consecutive euthyroid children were given, before and until the end of their radiotherapy on neck/mediastinum, L-thyroxine at TSH-suppressive doses. The 14 patients had adequate TSH suppression during irradiation in 8, inadequate in 6. The 8-year hypothyroidism-free-survival after irradiation was 75 ± 15% for the former group, 0% for the latter (P = 0.009). TSH suppression could have a protective effect on thyroid function as shown in a small group of patients with HL.
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Affiliation(s)
- Maura Massimino
- Pediatrics Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Milano, Italy.
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Bölling T, Geisenheiser A, Pape H, Martini C, Rübe C, Timmermann B, Fischedick K, Kortmann RD, Gerss J, Koch R, Willich N. Hypothyroidism after head-and-neck radiotherapy in children and adolescents: preliminary results of the "Registry for the Evaluation of Side Effects After Radiotherapy in Childhood and Adolescence" (RiSK). Int J Radiat Oncol Biol Phys 2010; 81:e787-91. [PMID: 21167655 DOI: 10.1016/j.ijrobp.2010.10.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 09/22/2010] [Accepted: 10/02/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE The "Registry for the Evaluation of Side Effects After Radiotherapy in Childhood and Adolescence" (RiSK) has been established to prospectively characterize dose-volume effects of radiation in terms of side effects. The aim of this analysis was to characterize the function of the thyroid gland after radiotherapy to the head-and-neck region in children and adolescents. METHODS AND MATERIALS Detailed information regarding radiation doses to at-risk organs has been collected across Germany since 2001. Thyroid function was evaluated by blood value examinations of thyroid-stimulating hormone, triiodothyronine, and thyroxine. Information regarding thyroid hormone substitution was requested from the treating physicians. RESULTS Until May 2009, 1,086 patients from 62 centers were recruited, including 404 patients (median age, 10.9 years) who had received radiotherapy to the thyroid gland and/or hypophysis. Follow-up information was available for 264 patients (60.9%; median follow-up, 40 months), with 60 patients (22.7%) showing pathologic values. In comparison to patients treated with prophylactic cranial irradiation (median dose, 12 Gy), patients with radiation doses of 15 to 25 Gy to the thyroid gland had a hazard ratio of 3.072 (p=0.002) for the development of pathologic thyroid blood values. Patients with greater than 25 Gy to the thyroid gland and patients who underwent craniospinal irradiation had hazard ratios of 3.768 (p=0.009) and 5.674 (p<0.001), respectively. The cumulative incidence of thyroid hormone substitution therapy did not differ between defined subgroups. CONCLUSIONS Radiation-induced thyroid function impairment, including damage to the thyroid gland and/or hypophysis, can frequently be observed after radiotherapy in children. A structured follow-up examination is advised.
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Affiliation(s)
- Tobias Bölling
- Department of Radiotherapy, University Hospital of Münster, and Department of Medical Informatics and Biomathematics, University of Münster, Münster, Germany.
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Lin JD. Thyroid Cancer in Thyroid Nodules Diagnosed Using Ultrasonography and Fine Needle Aspiration Cytology. J Med Ultrasound 2010. [DOI: 10.1016/s0929-6441(10)60014-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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