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Effect of Suppressive Levothyroxine Therapy on Bone Mineral Density in Young Patients with Differentiated Thyroid Carcinoma. Metabolites 2022; 12:metabo12090842. [PMID: 36144246 PMCID: PMC9500704 DOI: 10.3390/metabo12090842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
Suppressive levothyroxine therapy (sT4) is a cornerstone in the management of differentiated thyroid cancer (DTC). Long-term sT4 may affect bone mineral density (BMD). We evaluated the effect of sT4 on the bone mass of young DTC patients. In this cross-sectional study, BMD was evaluated via dual-energy X-ray absorptiometry in DTC patients younger than 25 years at diagnosis and undergoing sT4 for ≥1 year. The two control groups comprised patients matched for sex, age, and body-mass-index who were thyroidectomized for indications other than DTC and undergoing L-T4-replacement therapy, and healthy individuals with no prior known thyroid disease. Ninety-three participants were included (thirty-one in each group). There were no differences in the mean age, female sex (77.4% in all groups), or BMI between the sT4 group and each control group. The median TSH level was lower (0.4 [0.04–6.5] vs. 2.7 [0.8–8.5] mIU/mL, p = 0.01) and the mean L-T4 mcg/Kg levels were higher (2.4 ± 0.6 vs. 1.6 ± 0.3, p = 0.01) in the sT4 group compared to the L-T4-replacement therapy group. Lumbar spine, femoral neck, and total femur BMD were all similar among the groups. sT4 does not impact BMD in young DTC patients after a median time of suppression of 8 years. These findings may help in the decision-making and risk/benefit evaluation of sT4 for this population.
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Won HR, Jeon E, Chang JW, Kang YE, Song K, Kim SW, Lim DM, Ha TK, Chung KW, Kim HJ, Park YJ, Koo BS. Is Maintaining Thyroid-Stimulating Hormone Effective in Patients Undergoing Thyroid Lobectomy for Low-Risk Differentiated Thyroid Cancer? A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14061470. [PMID: 35326621 PMCID: PMC8946503 DOI: 10.3390/cancers14061470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 12/19/2022] Open
Abstract
Simple Summary In order to reduce the recurrence rate after surgical treatment of differentiated thyroid cancer (DTC), suppression of thyroid-stimulating hormone (TSH) or maintenance of a certain level after surgery are important. However, the effectiveness of TSH maintenance in the mid to lower reference range (0.5–2 mU/L) in patients undergoing thyroid lobectomy for low-risk DTC is uncertain. In this systematic review and meta-analysis, we compared and analyzed the recurrence rate according to whether TSH maintenance was performed in patients who underwent thyroid lobectomy for low-risk DTC. There was no difference in the recurrence rate with or without TSH control. Therefore, the recommendation to maintain TSH to reduce the recurrence rate after thyroid lobectomy is still controversial. Abstract There is no clear evidence that post-operative maintenance of thyroid-stimulating hormone (TSH) in the mid to lower reference range (0.5–2 mU/L) improves prognosis in patients undergoing thyroid lobectomy for low-risk differentiated thyroid cancer (DTC). The purpose of this systematic review and meta-analysis was to compare and analyze the recurrence rate according to whether the serum TSH level was maintained below 2 mU/L in patients who underwent thyroid lobectomy for low-risk DTC. Clinical data and outcomes were collected from MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. The inclusion criteria were related studies on TSH maintenance or serum TSH concentration after surgery for DTC. Seven observational studies with a total of 3974 patients were included in this study. In the patients who received TSH maintenance less than 2 mU/L, the recurrence rate during the follow-up period was 2.3%. A subgroup analysis of five studies showed that the odds ratio for recurrence in patients who received TSH maintenance was 1.45 (p-value = 0.45) compared to patients who did not receive TSH maintenance. In conclusion, the evidence for the effectiveness of post-operative TSH maintenance less than 2 mU/L in patients undergoing thyroid lobectomy for low-risk DTC is insufficient.
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Affiliation(s)
- Ho-Ryun Won
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Sejong Hospital, Sejong 30099, Korea
| | - Eonju Jeon
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu 42472, Korea;
| | - Jae Won Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Yea Eun Kang
- Division of Endocrinology and Metabolism, Departments of Internal Medicine, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Kunho Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Sungkyunkwan University School of Medicine, Seoul 16419, Korea;
| | - Dong Mee Lim
- Department of Internal Medicine, Konyang University Hospital, Daejeon 35365, Korea;
| | - Tae Kwun Ha
- Department of Surgery, Inje University Busan Paik Hospital, Busan 47392, Korea;
| | - Ki-Wook Chung
- Department of Surgery, Ulsan University College of Medicine, Seoul 05505, Korea;
| | - Hyo-Jeong Kim
- Department of Internal Medicine, Eulji University College of Medicine, Daejeon 34824, Korea;
| | - Young Joo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: (Y.J.P.); (B.S.K.)
| | - Bon Seok Koo
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon 35015, Korea; (H.-R.W.); (J.W.C.)
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University Hospital, Daejeon 35015, Korea;
- Correspondence: (Y.J.P.); (B.S.K.)
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Wang LY, Smith AW, Palmer FL, Tuttle RM, Mahrous A, Nixon IJ, Patel SG, Ganly I, Fagin JA, Boucai L. Thyrotropin suppression increases the risk of osteoporosis without decreasing recurrence in ATA low- and intermediate-risk patients with differentiated thyroid carcinoma. Thyroid 2015; 25:300-7. [PMID: 25386760 PMCID: PMC6916125 DOI: 10.1089/thy.2014.0287] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Levothyroxine suppression of thyrotropin (TSH) is broadly applied to patients with thyroid cancer despite lack of consensus on the optimal TSH concentration necessary to reduce cancer recurrence while minimizing toxicity from subclinical hyperthyroidism. The objectives of this study were to examine the beneficial effects and the cardiac and skeletal toxicity of TSH suppression in well-differentiated thyroid carcinoma (DTC). METHODS A total of 771 patients (569 women) at ATA low or intermediate risk of recurrence, with a mean age of 48±14 years, and undergoing total thyroidectomy at a tertiary care center between 2000 and 2006 were followed for a median of six and a half years. They were divided into a suppressed TSH group (median TSH ≤0.4 mIU/L) and a nonsuppressed group (median TSH >0.4 mIU/L). Structural recurrence of thyroid cancer, postoperative atrial fibrillation (AF), and osteoporosis were examined in the two groups. Osteoporosis was only examined in women. RESULTS A total of 43/771 (5.6%) patients recurred, 29/739 (3.9%) patients were diagnosed with postoperative osteoporosis, and 17/756 (2.3 %) were diagnosed with postoperative AF. Despite similar rates of recurrence (HR 1.02, p=0.956 [CI 0.54-1.91]), patients treated to a median TSH ≤0.4 mIU/L were at increased postoperative risk of a composite outcome of AF and osteoporosis (HR 2.1, p=0.05 [CI 1.001-4.3]) compared to those not suppressed. A differential risk of AF alone (HR 0.78, p=0.63 [CI 0.3-2.1]) was not detected, but postoperative osteoporosis was increased among women with a suppressed TSH compared to those not suppressed (HR 3.5, p=0.023 [CI 1.2-10.2]). The increased risk of postoperative osteoporosis disappeared when the patient's median TSH was maintained around 1 mIU/L. CONCLUSION TSH suppression significantly increases the risk of postoperative osteoporosis without changing tumor recurrence in ATA low- and intermediate-risk patients with DTC. Future interventions should focus on avoiding harm in indolent disease.
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Affiliation(s)
- Laura Y. Wang
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew W. Smith
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Frank L. Palmer
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - R. Michael Tuttle
- Department of Medicine, Division of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Azhar Mahrous
- Department of Medicine, Division of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Iain J. Nixon
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Snehal G. Patel
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ian Ganly
- Department of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A. Fagin
- Department of Medicine, Division of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura Boucai
- Department of Medicine, Division of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, New York
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Biondi B, Cooper DS. Benefits of thyrotropin suppression versus the risks of adverse effects in differentiated thyroid cancer. Thyroid 2010; 20:135-46. [PMID: 20151821 DOI: 10.1089/thy.2009.0311] [Citation(s) in RCA: 185] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Despite clinical practice guidelines for the management of differentiated thyroid cancer (DTC), there are no recommendations on the optimal serum thyrotropin (TSH) concentration to reduce tumor recurrences and improve survival, while ensuring an optimal quality of life with minimal adverse effects. The aim of this review was to provide a risk-adapted management scheme for levothyroxine (L-T4) therapy in patients with DTC. The objective was to establish which patients require complete suppression of serum TSH levels, given their risk of recurrent or metastatic DTC, and how potential adverse effects on the heart and skeleton, induced by subclinical hyperthyroidism, in concert with advanced age and comorbidities, may influence the degree of TSH suppression. SUMMARY A risk-stratified approach to predict the rate of recurrence and death from thyroid cancer was based on the recently revised American Thyroid Association guidelines. A stratified approach to predict the risk from the adverse effects of L-T4 was devised, taking into account the age of the patient, as well as the presence of preexisting cardiovascular and skeletal risk factors that might predispose to the development of long-term adverse cardiovascular or skeletal outcomes, particularly increased heart rate and left ventricular mass, atrial fibrillation, and osteoporosis. Nine potential patient categories can be defined, with differing TSH targets for both initial and long-term L-T4 therapy. CONCLUSION Before deciding on the degree of TSH suppression during initial and long-term L-T4 treatment in patients with DTC, it is necessary to consider the aggressiveness of DTC, as well as the potential for adverse effects induced by iatrogenic subclinical hyperthyroidism. More aggressive TSH suppression is indicated in patients with high-risk disease or recurrent tumor, whereas less aggressive TSH suppression is reasonable in low-risk patients. In patients with high-risk DTC and an equally high risk of adverse effects, long-term treatment with L-T4 therapy should be individualized and balanced against the potential for adverse effects. In patients with an intermediate risk for thyroid cancer recurrence and a high risk of adverse effects of therapy, the degree of TSH suppression should be reevaluated during the follow-up period. Normalization of serum TSH is advisable for long-term treatment of disease-free elderly patients with DTC and significant comorbidities.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical and Molecular Endocrinology and Oncology, University of Naples Federico II, Naples, Italy.
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McGriff NJ, Csako G, Gourgiotis L, Lori C G, Pucino F, Sarlis NJ. Effects of thyroid hormone suppression therapy on adverse clinical outcomes in thyroid cancer. Ann Med 2002; 34:554-64. [PMID: 12553495 DOI: 10.1080/078538902321117760] [Citation(s) in RCA: 178] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Long-term thyroid hormone (TH) therapy aiming at the suppression of serum thyrotropin (TSH) has been traditionally used in the management of well differentiated thyroid cancer (ThyrCa). However, formal validation of the effects of thyroid hormone suppression therapy (THST) through randomized controlled trials is lacking. Additionally, the role - if any - of TSH effect at low ambient concentrations upon human thyroid tumorigenesis remains unclear. AIM Evaluation of the effect of THST on the clinical outcomes of papillary and/or follicular ThyrCa. METHODS By using a quantitative research synthesis approach in a cumulative ThyrCa cohort, we evaluated the effect of THST on the likelihood of major adverse clinical events (disease progression/recurrence and death). A total of 28 clinical trials published during the period 1934-2001 were identified; only 10 were amenable to meta-analysis. Causality was assessed by Hill criteria. RESULTS Out of 4, 174 patients with ThyrCa, 2, 880 (69%) were reported as being on THST. Meta-analysis showed that the group of patients who received THST had a decreased risk of major adverse clinical events (RR = 0.73; Cl = 0.60-0.88; P < 0.05). Further, by applying a Likert scale, 15/17 interpretable studies showed either a 'likely' or 'questionable' beneficial effect of THST. Assessment of causality between TSHT and reduction of major adverse clinical events suggested a probable association. CONCLUSIONS THST appears justified in ThyrCa patients following initial therapy. As most primary studies were imperfect, future research will better define the effect of THST upon ThyrCa clinical outcomes.
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Affiliation(s)
- Nayahmka J McGriff
- Department of Pharmacy, Warren G. Magnuson Clinical Center, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), Building 10, Room 8D12C, 10 Center Drive, MSC 1758 Bethesda, MD 20892-1758, USA
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van Tol KM, de Vries EG, Dullaart RP, Links TP. Differentiated thyroid carcinoma in the elderly. Crit Rev Oncol Hematol 2001; 38:79-91. [PMID: 11255083 DOI: 10.1016/s1040-8428(00)00127-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The overall prognosis of patients with differentiated thyroid cancer is excellent, but the prognosis is rapidly worsening, when the disease is diagnosed in elderly patients. Old patients more often present with poor prognostic features, such as large tumors, follicular or Hürthle cell subtypes, extrathyroidal growth and distant metastases. Therefore, an optimal therapeutic approach is recommended. Current therapy includes a total thyroidectomy, if necessary combined with a lymph node dissection and followed by high dose radioiodine ablation. Radioiodine therapy in elderly patients meets specific problems, concerning thyroid hormone withdrawal, side effects of 131I and nursing problems. Additional treatment of residual, recurrent or metastatic disease must be tailored, according to the stage of the disease, and should not be denied on the basis of chronological age. Lifelong treatment with suppressive thyroid hormone therapy does not lead to important long-term side effects at old age.
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Affiliation(s)
- K M van Tol
- Department of Endocrinology, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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