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Milano MT, Vargo JA, Yorke ED, Ronckers CM, Kremer LC, Chafe SMJ, van Santen HM, Marks LB, Bentzen SM, Constine LS, Vogelius IR. Primary Hypothyroidism in Childhood Cancer Survivors Treated With Radiation Therapy: A PENTEC Comprehensive Review. Int J Radiat Oncol Biol Phys 2024; 119:482-493. [PMID: 33810948 DOI: 10.1016/j.ijrobp.2021.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/04/2021] [Accepted: 02/01/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE From the Pediatric Normal Tissue Effects in the Clinic (PENTEC) initiative, a systematic review and meta-analysis of publications reporting on radiation dose-volume effects for risk of primary hypothyroidism after radiation therapy for pediatric malignancies was performed. METHODS AND MATERIALS All studies included childhood cancer survivors, diagnosed at age <21 years, whose radiation therapy fields exposed the thyroid gland and who were followed for primary hypothyroidism. Children who received pituitary-hypothalamic or total-body irradiation were excluded. PubMed and the Cochrane Library were searched for studies published from 1970 to 2017. Data on age at treatment, patient sex, radiation dose to neck or thyroid gland, specific endpoints for hypothyroidism that were used in the studies, and reported risks of hypothyroidism were collected. Radiation dose-volume effects were modeled using logistic dose response. Relative excess risk of hypothyroidism as a function of age at treatment and sex was assessed by meta-analysis of reported relative risks (RR) and odds ratios. RESULTS Fifteen publications (of 1709 identified) were included for systematic review. Eight studies reported data amenable for dose-response analysis. At mean thyroid doses of 10, 20, and 30 Gy, predicted rates of uncompensated (clinical) hypothyroidism were 4%, 7%, and 13%, respectively. Predicted rates of compensated (subclinical) hypothyroidism were 12%, 25%, and 44% after thyroid doses of 10, 20, and 30 Gy, respectively. Female sex (RR = 1.7, P < .0001) and age >15 years at radiation therapy (RR = 1.3, P = .005) were associated with higher risks of hypothyroidism. After a mean thyroid dose of 20 Gy, predicted risks of hypothyroidism were 13% for males <14 years of age, increasing to 29% for females >15 years of age. CONCLUSION A radiation dose response for risk of hypothyroidism is evident; a threshold radiation dose associated with no risk is not observed. Thyroid dose exposure should be minimized when feasible. Data on hypothyroidism after radiation therapy should be better reported to facilitate pooled analyses.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.
| | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ellen D Yorke
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cécile M Ronckers
- Department of Pediatric Oncology, Emma Children's Hospital/Amsterdam UMC Location AMC, Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Institute for Biostatistics and Registry Research, Brandenburg Medical School-Theodor Fontane, Neuruppin, Germany
| | - Leontien C Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Amsterdam UMC Location AMC, Amsterdam, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Susan M J Chafe
- Division of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Hanneke M van Santen
- University Medical Center Utrecht and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Søren M Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Ivan R Vogelius
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Carlé A, Karmisholt JS, Knudsen N, Perrild H, Thuesen BH, Ovesen L, Rasmussen LB, Pedersen IB. Does Subclinical Hypothyroidism Add Any Symptoms? Evidence from a Danish Population-Based Study. Am J Med 2021; 134:1115-1126.e1. [PMID: 33872585 DOI: 10.1016/j.amjmed.2021.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/31/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few studies have scrutinized the spectrum of symptoms in subclinical hypothyroidism. METHODS From 3 Danish Investigation on Iodine Intake and Thyroid Diseases (DanThyr) cross-sectional surveys performed in the period 1997 to 2005, a total of 8903 subjects participated in a comprehensive investigation including blood samples and questionnaires on previous diseases, smoking habits, alcohol intake, and education. From the 3 surveys we included patients with subclinical hypothyroidism (n = 376) and euthyroid controls (n = 7619). We explored to what extent patients with subclinical hypothyroidism reported 13 previously identified hypothyroidism-associated symptoms (tiredness, dry skin, mood lability, constipation, palpitations, restlessness, shortness of breath, wheezing, globus sensation, difficulty swallowing, hair loss, dizziness/vertigo, and anterior neck pain). In various uni- and multivariate regression models we searched for circumstances predicting why some patients have more complaints than others. RESULTS Subclinically hypothyroid patients did not report higher hypothyroidism score [(median, interquartile range), 2 (0-4) vs 2 (0-4), P = .25] compared with euthyroid controls. Within the group of subclinical hypothyroid patients, comorbidity had the highest impact on symptoms (tiredness, shortness of breath, wheezing; all P < .001); TSH level had no impact on symptom score; and younger age was accompanied by higher mental burden (tiredness, P < .001; mood lability, P < .001; restlessness, P = .012), whereas shortness of breath was associated with high body mass index (P < .001) and smoking (P = .007). CONCLUSION Patients with a thyroid function test suggesting subclinical hypothyroidism do not experience thyroid disease-related symptoms more often than euthyroid subjects. In subclinical hypothyroidism, clinicians should focus on concomitant diseases rather than expecting symptomatic relief following levothyroxine substitution.
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Affiliation(s)
- Allan Carlé
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark.
| | - Jesper Scott Karmisholt
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark
| | - Nils Knudsen
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Hans Perrild
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | - Lars Ovesen
- Department of Internal Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Lone Banke Rasmussen
- Department of Endocrinology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Inge Bülow Pedersen
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Institute, Aalborg University, Denmark
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Jamshidi AA, Rokni Lamouki GR. An algorithmic treatment strategy for the inhibition of type-II deiodinase enzyme on thyroid secretion hormones. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dzierlenga MW, Allen BC, Clewell HJ, Longnecker MP. Pharmacokinetic bias analysis of an association between clinical thyroid disease and two perfluoroalkyl substances. ENVIRONMENT INTERNATIONAL 2020; 141:105784. [PMID: 32408218 DOI: 10.1016/j.envint.2020.105784] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/06/2020] [Accepted: 04/30/2020] [Indexed: 06/11/2023]
Abstract
Exposure to perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) has been associated with the occurrence of thyroid disease in some epidemiologic studies. We hypothesized that in a specific epidemiologic study based on the National Health and Nutrition Examination Survey, the association of clinical thyroid disease with serum concentration of PFOA and PFOS was due to reverse causality. Thyroid hormone affects glomerular filtration, which in turn affects excretion of PFOA and PFOS. We evaluated this by linking a model of thyroid disease status over the lifetime to a physiologically based pharmacokinetic model of PFOA and PFOS. Using Monte Carlo methods, we simulated the target study population and analyzed the data using multivariable logistic regression. The target and simulated populations were similar with respect to age, estimated glomerular filtration rate, serum concentrations of PFOA and PFOS, and prevalence of clinical thyroid disease. The analysis showed little or no evidence of bias from the hypothesized mechanism. The largest bias was for the fourth quartile of PFOA in females, with an odds ratio of 0.93 (95% CI, 0.90, 0.97). The reported odds ratio of clinical thyroid disease for this group was 1.63 (1.07, 2.47), and if it were corrected for the bias would have been 1.74 (1.14, 2.65). Our results suggest that little of the reported association in the target study was due to reverse causality.
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Dzierlenga MW, Moreau M, Song G, Mallick P, Ward PL, Campbell JL, Housand C, Yoon M, Allen BC, Clewell HJ, Longnecker MP. Quantitative bias analysis of the association between subclinical thyroid disease and two perfluoroalkyl substances in a single study. ENVIRONMENTAL RESEARCH 2020; 182:109017. [PMID: 31865168 DOI: 10.1016/j.envres.2019.109017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/08/2019] [Accepted: 12/06/2019] [Indexed: 05/23/2023]
Abstract
Exposure to perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS) has been associated with the occurrence of thyroid disease in some epidemiologic studies. We hypothesized that in a specific epidemiologic study based on the National Health and Nutrition Examination Survey, the association of subclinical thyroid disease with serum concentration of PFOA and PFOS was due to reverse causality. Thyroid hormone affects glomerular filtration, which in turn affects excretion of PFOA and PFOS. We evaluated this by linking a model of thyroid disease status over the lifetime to physiologically based pharmacokinetic models of PFOA and PFOS. Using Monte Carlo methods, we simulated the target study population and analyzed the data using multivariable logistic regression. The target and simulated populations were similar with respect to age, estimated glomerular filtration rate, serum concentrations of PFOA and PFOS, and prevalence of subclinical thyroid disease. Our findings suggest that in the target study the associations with subclinical hypothyroidism were overstated and the results for subclinical hyperthyroidism were, in general, understated. For example, for subclinical hypothyroidism in men, the reported odds ratio per ln(PFOS) increase was 1.98 (95% CI 1.19-3.28), whereas in the simulated data the bias due to reverse causality gave an odds ratio of 1.19 (1.16-1.23). Our results provide evidence of bias due to reverse causality in a specific cross-sectional study of subclinical thyroid disease with exposure to PFOA and PFOS among adults.
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Affiliation(s)
| | | | - Gina Song
- ScitoVation, LLC, Research Triangle Park, NC, USA
| | | | | | | | | | - Miyoung Yoon
- ScitoVation, LLC, Research Triangle Park, NC, USA; ToxStrategies, Research Triangle Park, NC, USA
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