1
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Heinzel A, Müller D, van Santen HM, Clement SC, Schneider AB, Verburg FA. The effect of surveillance for differentiated thyroid carcinoma in childhood cancer survivors on survival rates: a decision-tree-based analysis. Endocr Connect 2022; 11:e220092. [PMID: 36240044 PMCID: PMC9716375 DOI: 10.1530/ec-22-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
Background Childhood cancer survivors (CCS) who received radiation therapy exposing the thyroid gland are at increased risk of developing differentiated thyroid cancer (DTC). Therefore, the International Guideline Harmonization Group (IGHG) on late effects of childhood cancer therefore recommends surveillance. It is unclear whether surveillance reduces mortality. Aim The aim of this study was to compare four strategies for DTC surveillance in CCS with the aim of reducing mortality: Strategy-1, no surveillance; Strategy-2, ultrasound alone; Strategy-3, ultrasound followed by fine-needle biopsy (FNB); Strategy-4, palpation followed by ultrasound and FNB. Materials and methods A decision tree was formulated with 10-year thyroid cancer-specific survival as the endpoint, based on data extracted from literature. Results It was calculated that 12.6% of CCS will develop DTC. Using Strategy-1, all CCS with DTC would erroneously not be operated upon, but no CCS would have unnecessary surgery. With Strategy-2, all CCS with and 55.6% of CCS without DTC would be operated. Using Strategy-3, 11.1% of CCS with DTC would be correctly operated upon, 11.2% without DTC would be operated upon and 1.5% with DTC would not be operated upon. With Strategy-4, these percentages would be 6.8, 3.9 and 5.8%, respectively. Median 10-year survival rates would be equal across strategies (0.997). Conclusion Different surveillance strategies for DTC in CCS all result in the same high DTC survival. Therefore, the indication for surveillance may lie in a reduction of surgery-related morbidity rather than DTC-related mortality. In accordance with the IGHG guidelines, the precise strategy should be decided upon in a process of shared decision-making.
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Affiliation(s)
- Alexander Heinzel
- RWTH University Hospital Aachen, Department of Nuclear Medicine, Aachen, Germany
| | - Dirk Müller
- Institute for Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany
| | - Hanneke M van Santen
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Department of Pediatric Endocrinology, Utrecht, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Sarah C Clement
- Wilhelmina Children’s Hospital, University Medical Center Utrecht, Department of Pediatric Endocrinology, Utrecht, The Netherlands
- Emma Children’s Hospital, Amsterdam UMC, Department of Pediatrics, Amsterdam, The Netherlands
| | - Arthur B Schneider
- University of Illinois at Chicago, Department of Medicine, Chicago, IL, USA
| | - Frederik A Verburg
- Erasmus MC Rotterdam, Department of Radiology & Nuclear Medicine, Rotterdam, The Netherlands
- University Hospital Würzburg, Department of Nuclear Medicine, Würzburg, Germany
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2
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Kitahara CM, Schneider AB. Epidemiology of Thyroid Cancer. Cancer Epidemiol Biomarkers Prev 2022; 31:1284-1297. [PMID: 35775227 PMCID: PMC9473679 DOI: 10.1158/1055-9965.epi-21-1440] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/23/2022] [Accepted: 04/11/2022] [Indexed: 01/03/2023] Open
Affiliation(s)
- Cari M. Kitahara
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Arthur B. Schneider
- University of Illinois at Chicago, College of Medicine, Department of Medicine, Chicago, IL, USA
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3
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Toft DJ, Schneider AB. Protecting the Thyroid in Times of Conflict (Ukraine 2022). Thyroid 2022; 32:607-610. [PMID: 35469429 DOI: 10.1089/thy.2022.0135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Daniel J Toft
- Department of Endocrinology, Diabetes and Metabolism and University of Illinois at Chicago, Chicago, Illinois, USA
| | - Arthur B Schneider
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract
Background: In 2013, the American Thyroid Association (ATA) issued a "Policy Statement on Thyroid Shielding During Diagnostic Medical and Dental Radiology." The recently updated National Council on Radiation Protection and Measurement Radiation Protection in Dentistry and Oral and Maxillofacial Imaging (NCRP Report No. 177) prompts this review of progress related to patient thyroid shielding since the ATA statement was published. Summary: Relevant publications appearing since the ATA statement were identified by querying PubMed for "thyroid and dental and (collar or shielding)" and substituting specific dental radiographic procedures in the search. The search was expanded by reviewing the cited papers in the PubMed-retrieved papers and by use of the Web of Science to retrieve papers citing the PubMed retrieved publications. Although many quantitative studies have appeared reflective of current dental radiographic instrumentation and practice, much more can be done to foster minimizing radiation to the thyroid. Conclusions: We list seven areas that should be pursued. Among them are harmonizing guidelines for the use of thyroid collars based on the recent studies and a comprehensive survey of current dental radiological practice patterns.
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Affiliation(s)
- Arthur B Schneider
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
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van Santen HM, Alexander EK, Rivkees SA, Frey E, Clement SC, Dierselhuis MP, Lebbink CA, Links TP, Lorenz K, Peeters RP, Reiners C, Vriens MR, Nathan P, Schneider AB, Verburg F. Clinical considerations for the treatment of secondary differentiated thyroid carcinoma in childhood cancer survivors. Eur J Endocrinol 2020; 183:P1-P10. [PMID: 32508309 DOI: 10.1530/eje-20-0237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/04/2020] [Indexed: 11/08/2022]
Abstract
The incidence of differentiated thyroid carcinoma (DTC) has increased rapidly over the past several years. Thus far, the only conclusively established risk factor for developing DTC is exposure to ionizing radiation, especially when the exposure occurs in childhood. Since the number of childhood cancer survivors (CCS) is increasing due to improvements in treatment and supportive care, the number of patients who will develop DTC after surviving childhood cancer (secondary thyroid cancer) is also expected to rise. Currently, there are no recommendations for management of thyroid cancer specifically for patients who develop DTC as a consequence of cancer therapy during childhood. Since complications or late effects from prior cancer treatment may elevate the risk of toxicity from DTC therapy, the medical history of CCS should be considered carefully in choosing DTC treatment. In this paper, we emphasize how the occurrence and treatment of the initial childhood malignancy affects the medical and psychosocial factors that will play a role in the diagnosis and treatment of a secondary DTC. We present considerations for clinicians to use in the management of patients with secondary DTC, based on the available evidence combined with experience-based opinions of the authors.
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Affiliation(s)
- Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Erik K Alexander
- Department of Endocrinology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Scott A Rivkees
- Department of Pediatrics, University of Florida, Florida, USA
| | - Eva Frey
- Department of Pediatric Oncology, Vienna
| | - Sarah C Clement
- Department of Pediatrics, Free University Hospital Amsterdam, Amsterdam, the Netherlands
| | - Miranda P Dierselhuis
- Department of Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, the Netherlands
| | - Chantal A Lebbink
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center, Groningen, Netherlands Department of endocrinology, UMCG, Groningen, Netherlands
| | - Kerstin Lorenz
- Department of Visceral-, Vascular-, and Endocrine Surgery, Universityclinic Halle, Germany
| | - Robin P Peeters
- Department of Endocrinology, Erasmus Medical Center, the Netherlands
| | | | - Menno R Vriens
- Department of Endocrine Surgery, UMC Utrecht, Netherlands
| | - Paul Nathan
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Arthur B Schneider
- Department of Endocrinology, Diabetes, and Metabolism, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Frederik Verburg
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
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Vydro L, Kitahara CM, Lubin JH, Schneider AB, Mihailescu DV. Among Individuals Irradiated for Benign Conditions in Childhood, Developing Thyroid Cancer Does Not Affect All-Cause Survival. Thyroid 2020; 30:389-395. [PMID: 31797741 PMCID: PMC7133439 DOI: 10.1089/thy.2019.0439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Whether radiation-induced thyroid cancer affects survival rates has not been clearly elucidated. Survival could be affected by the thyroid cancer itself, its treatment, or by being a sign of susceptibility to other cancers. The objective of the current study was to determine if the development of thyroid cancer is associated with a differential survival in radiation-exposed individuals. Methods: We conducted a matched prospective cohort mortality follow-up study based on data from a cohort of 4296 individuals who were irradiated predominantly for enlarged tonsils during their childhood (between 1939 and 1962) and were prospectively followed since 1974. The study matched an irradiated subject who developed (was exposed to) thyroid cancer (a "case") and two irradiated subjects, who had not developed (were not exposed to) thyroid cancer ("controls") by the time of case incidence. The two controls were randomly matched to cases by sex, year of birth, age at radiation treatment, and radiation dose. Then, using a stratified Cox analysis, we compared survival time from the date of thyroid cancer diagnosis or time of selection to either date of death or the end of the observation period (December 31, 2016). Vital status and causes of death were determined using the National Death Index (1979-2016), the Social Security Death Index (1974-1979), and study files. Cause of death was categorized as cardiovascular, malignancy, or other. Results: A total of 1008 subjects were included in the analysis, including 353 thyroid cancer cases. At the end of the study period, 162 of 655 (24.7%) of individuals without thyroid cancer had died compared with 100 of 353 (28.3%) of the subjects with thyroid cancer. The hazard ratio (HR) for all-cause mortality, comparing the thyroid cancer cases to controls, was close to unity (HR = 1.01 [0.77-1.33]). HRs remained insignificant after eliminating matched sets with microcarcinomas, defined as tumor size <10 mm (HR = 1.39 [0.96-2.03]). Distribution of the causes of death taking into account age and the time of observation differed between cases and controls (p < 0.05). Neither increased cardiovascular-related nor malignancy-related mortality was associated with radiation-induced thyroid cancer. Conclusions: Among individuals irradiated for benign conditions in childhood, development of thyroid cancer was not associated with decreased all-cause survival.
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Affiliation(s)
- Leonid Vydro
- Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, Illinois
| | - Cari M. Kitahara
- Division of Cancer Epidemiology & Genetics, Radiation Epidemiology Branch, National Cancer Institute, Bethesda, Maryland
| | - Jay H. Lubin
- Division of Cancer Epidemiology & Genetics, Biostatistics Branch, National Cancer Institute, Bethesda, Maryland
| | - Arthur B. Schneider
- Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, Illinois
| | - Dan V. Mihailescu
- Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, Illinois
- Address correspondence to: Dan V. Mihailescu, MD, Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, 1819 West Polk Street, MC 640, Chicago, IL 60612
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Leung AM, Lubin JH, Schneider AB. Response to Cuttler et al. re: "Low-Dose Childhood Radiation Effects to the Thyroid Follow a Linear Dose-Response Trend and Persist Even 45+ Years After Exposure". Thyroid 2018; 28:680-681. [PMID: 29580180 PMCID: PMC6016093 DOI: 10.1089/thy.2018.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism; UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Jay H. Lubin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, DHHS, Bethesda, Maryland
| | - Arthur B. Schneider
- University of Illinois College of Medicine, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois
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8
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Shulan JM, Vydro L, Schneider AB, Mihailescu DV. Role of biomarkers in predicting the occurrence of thyroid neoplasms in radiation-exposed children. Endocr Relat Cancer 2018; 25:481-491. [PMID: 29453230 DOI: 10.1530/erc-17-0408] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/14/2018] [Indexed: 01/08/2023]
Abstract
With increasing numbers of childhood cancer survivors who were treated with radiation, there is a need to evaluate potential biomarkers that could signal an increased risk of developing thyroid cancer. We aimed to examine the relationships between thyrotropin and thyroglobulin levels and the risk of developing thyroid nodules and cancer in a cohort of radiation-exposed children. 764 subjects who were irradiated in the neck area as children were examined and followed for up to 25 years. All subjects underwent a clinical examination, measurements of thyrotropin, thyroglobulin levels and thyroid imaging. At baseline, 216 subjects had thyroid nodules and 548 did not. Of those with nodules, 176 underwent surgery with 55 confirmed thyroid cancers. During the follow-up, 147 subjects developed thyroid nodules including 22 with thyroid cancer. Thyroglobulin levels were higher in subjects with prevalent thyroid nodules (26.1 ng/mL vs 9.37 ng/mL; P < 0.001) and in those who had an initial normal examination but later developed thyroid nodules (11.2 ng/mL vs 8.87 ng/mL; P = 0.017). There was no relationship between baseline thyrotropin levels and the prevalent presence or absence of thyroid nodules, whether a prevalent neoplasm was benign or malignant, subsequent development of thyroid nodules during follow-up or whether an incident nodule was benign or malignant. In conclusion, in radiation-exposed children, higher thyroglobulin levels indicated an increased risk of developing thyroid nodules but did not differentiate between benign and malignant neoplasms. There was no association between the baseline TSH level and the risk of developing thyroid nodules or cancer.
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Affiliation(s)
| | | | | | - Dan V Mihailescu
- Division of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, Illinois, USA
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9
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Lubin JH, Adams MJ, Shore R, Holmberg E, Schneider AB, Hawkins MM, Robison LL, Inskip PD, Lundell M, Johansson R, Kleinerman RA, de Vathaire F, Damber L, Sadetzki S, Tucker M, Sakata R, Veiga LHS. Thyroid Cancer Following Childhood Low-Dose Radiation Exposure: A Pooled Analysis of Nine Cohorts. J Clin Endocrinol Metab 2017; 102:2575-2583. [PMID: 28323979 PMCID: PMC5505197 DOI: 10.1210/jc.2016-3529] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/02/2017] [Indexed: 12/18/2022]
Abstract
CONTEXT The increased use of diagnostic and therapeutic procedures that involve radiation raises concerns about radiation effects, particularly in children and the radiosensitive thyroid gland. OBJECTIVES Evaluation of relative risk (RR) trends for thyroid radiation doses <0.2 gray (Gy); evidence of a threshold dose; and possible modifiers of the dose-response, e.g., sex, age at exposure, time since exposure. DESIGN AND SETTING Pooled data from nine cohort studies of childhood external radiation exposure and thyroid cancer with individualized dose estimates, ≥1000 irradiated subjects or ≥10 thyroid cancer cases, with data limited to individuals receiving doses <0.2 Gy. PARTICIPANTS Cohorts included the following: childhood cancer survivors (n = 2); children treated for benign diseases (n = 6); and children who survived the atomic bombings in Japan (n = 1). There were 252 cases and 2,588,559 person-years in irradiated individuals and 142 cases and 1,865,957 person-years in nonirradiated individuals. INTERVENTION There were no interventions. MAIN OUTCOME MEASURE Incident thyroid cancers. RESULTS For both <0.2 and <0.1 Gy, RRs increased with thyroid dose (P < 0.01), without significant departure from linearity (P = 0.77 and P = 0.66, respectively). Estimates of threshold dose ranged from 0.0 to 0.03 Gy, with an upper 95% confidence bound of 0.04 Gy. The increasing dose-response trend persisted >45 years after exposure, was greater at younger age at exposure and younger attained age, and was similar by sex and number of treatments. CONCLUSIONS Our analyses reaffirmed linearity of the dose response as the most plausible relationship for "as low as reasonably achievable" assessments for pediatric low-dose radiation-associated thyroid cancer risk.
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Affiliation(s)
- Jay H. Lubin
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892
| | - M. Jacob Adams
- University of Rochester School of Medicine and Dentistry, Department of Public Health Sciences, Rochester, New York 14642
| | - Roy Shore
- Radiation Effects Research Foundation, Hiroshima 732-0815, Japan
| | - Erik Holmberg
- Department of Oncology and Radiation Physics and the Oncological Centre, Sahlgrenska University Hospital, S-413-45 Goteborg, Sweden
| | - Arthur B. Schneider
- University of Illinois College of Medicine, Section of Endocrinology, Diabetes, and Metabolism, Chicago, Illinois 60612
| | - Michael M. Hawkins
- Centre for Childhood Cancer Survivor Studies, Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee 38105-3678
| | - Peter D. Inskip
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892
| | - Marie Lundell
- Department of Medical Physics, Radiumhemmet, Karolinska University Hospital and Karolinska Institute, SE-171 76 Stockholm, Sweden
| | - Robert Johansson
- Oncology, Department of Radiation Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Ruth A. Kleinerman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892
| | - Florent de Vathaire
- Cancer Epidemiology Research Unit, National Institute for Health and Medical Research–Institut Gustave Roussy, 94 805 Villejuif, France
| | - Lena Damber
- Oncology, Department of Radiation Sciences, Umeå University, 901 87 Umeå, Sweden
| | - Siegal Sadetzki
- Cancer and Radiation Epidemiology Unit, Gertner Institute, Chaim Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Tel Hashomer, 52621 Israel
| | - Margaret Tucker
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20892
| | - Ritsu Sakata
- Radiation Effects Research Foundation, Hiroshima 732-0815, Japan
| | - Lene H. S. Veiga
- Institute for Radiation Protection and Dosimetry, Brazilian Nuclear Energy Commission, 22783-127 Rio de Janeiro, Brazil
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Leung AM, Bauer AJ, Benvenga S, Brenner AV, Hennessey JV, Hurley JR, Milan SA, Schneider AB, Sundaram K, Toft DJ. American Thyroid Association Scientific Statement on the Use of Potassium Iodide Ingestion in a Nuclear Emergency. Thyroid 2017; 27:865-877. [PMID: 28537500 PMCID: PMC5561443 DOI: 10.1089/thy.2017.0054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This document serves to summarize the issues and the American Thyroid Association (ATA) position regarding the use of potassium iodide as a thyroid blocking agent in the event of a nuclear accident. The purpose is to provide a review and updated position statement regarding the advanced distribution, stockpiling, and availability of potassium iodide in the event of nuclear radiation emergencies in the United States.
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Affiliation(s)
- Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Andrew J. Bauer
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, The University of Pennsylvania, The Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina School of Medicine, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology and Women's Endocrine Health, University hospital Policlinico G Martino, Messina, Italy
| | - Alina V. Brenner
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - James V. Hennessey
- Department of Endocrinology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - James R. Hurley
- Division of Endocrinology, Diabetes, and Metabolism; Joan and Sanford I. Weill Department of Medicine; Weill Cornell Medical College, New York, New York
| | - Stacey A. Milan
- Department of General Surgery, Division of Endocrine Surgery, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Arthur B. Schneider
- Section of Endocrinology, Diabetes and Metabolism; University of Illinois College of Medicine, Chicago, Illinois
| | | | - Daniel J. Toft
- Division of Endocrinology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Veiga LHS, Holmberg E, Anderson H, Pottern L, Sadetzki S, Adams MJ, Sakata R, Schneider AB, Inskip P, Bhatti P, Johansson R, Neta G, Shore R, de Vathaire F, Damber L, Kleinerman R, Hawkins MM, Tucker M, Lundell M, Lubin JH. Thyroid Cancer after Childhood Exposure to External Radiation: An Updated Pooled Analysis of 12 Studies. Radiat Res 2016; 185:473-84. [PMID: 27128740 DOI: 10.1667/rr14213.1] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Studies have causally linked external thyroid radiation exposure in childhood with thyroid cancer. In 1995, investigators conducted relative risk analyses of pooled data from seven epidemiologic studies. Doses were mostly <10 Gy, although childhood cancer therapies can result in thyroid doses >50 Gy. We pooled data from 12 studies of thyroid cancer patients who were exposed to radiation in childhood (ages <20 years), more than doubling the data, including 1,070 (927 exposed) thyroid cancers and 5.3 million (3.4 million exposed) person-years. Relative risks increased supralinearly through 2-4 Gy, leveled off between 10-30 Gy and declined thereafter, remaining significantly elevated above 50 Gy. There was a significant relative risk trend for doses <0.10 Gy (P < 0.01), with no departure from linearity (P = 0.36). We observed radiogenic effects for both papillary and nonpapillary tumors. Estimates of excess relative risk per Gy (ERR/Gy) were homogeneous by sex (P = 0.35) and number of radiation treatments (P = 0.84) and increased with decreasing age at the time of exposure. The ERR/Gy estimate was significant within ten years of radiation exposure, 2.76 (95% CI, 0.94-4.98), based on 42 exposed cases, and remained elevated 50 years and more after exposure. Finally, exposure to chemotherapy was significantly associated with thyroid cancer, with results supporting a nonsynergistic (additive) association with radiation.
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Affiliation(s)
- Lene H S Veiga
- a Divisions of Cancer Epidemiology and Genetics and.,c Institute for Radiation Protection and Dosimetry, Brazilian Nuclear Energy Commission, Rio de Janeiro, Brazil
| | - Erik Holmberg
- d Department of Oncology and Radiation Physics and the Oncological Centre, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Harald Anderson
- e Department of Cancer Epidemiology, Lund University, Lund, Sweden;,f Representing the Nordic Countries Childhood Cancer Survival Group
| | - Linda Pottern
- g Captain, United States Public Health Service (retired), Bethesda, Maryland
| | - Siegal Sadetzki
- h Cancer and Radiation Epidemiology Unit, The Gertner Institute, Chaim Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Jacob Adams
- i University of Rochester School of Medicine and Dentistry, Department of Public Health Sciences, Rochester, New York
| | - Ritsu Sakata
- j Radiation Effects Research Foundation, Hiroshima, Japan (retired)
| | - Arthur B Schneider
- k University of Illinois College of Medicine, Section of Endocrinology, Diabetes and Metabolism, Chicago, Illinois
| | - Peter Inskip
- a Divisions of Cancer Epidemiology and Genetics and
| | - Parveen Bhatti
- l Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Robert Johansson
- m Oncology, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Gila Neta
- b Cancer Control and Population Sciences, National Cancer Institute, NIH, DHHS, Bethesda, Maryland
| | - Roy Shore
- j Radiation Effects Research Foundation, Hiroshima, Japan (retired)
| | - Florent de Vathaire
- n Cancer Epidemiology Research Unit, National Institute for Health and Medical Research-Institut Gustave Roussy, Villejuif, France
| | - Lena Damber
- m Oncology, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | | | - Michael M Hawkins
- Centre for Childhood Cancer Survivor Studies, Department of Public Health and Epidemiology, University of Birmingham, Birmingham, United Kingdom; and
| | | | - Marie Lundell
- p Department of Medical Physics, Radiumhemmet, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Jay H Lubin
- a Divisions of Cancer Epidemiology and Genetics and
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12
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Kitahara CM, McCullough ML, Franceschi S, Rinaldi S, Wolk A, Neta G, Olov Adami H, Anderson K, Andreotti G, Beane Freeman LE, Bernstein L, Buring JE, Clavel-Chapelon F, De Roo LA, Gao YT, Gaziano JM, Giles GG, Håkansson N, Horn-Ross PL, Kirsh VA, Linet MS, MacInnis RJ, Orsini N, Park Y, Patel AV, Purdue MP, Riboli E, Robien K, Rohan T, Sandler DP, Schairer C, Schneider AB, Sesso HD, Shu XO, Singh PN, van den Brandt PA, Ward E, Weiderpass E, White E, Xiang YB, Zeleniuch-Jacquotte A, Zheng W, Hartge P, Berrington de González A. Anthropometric Factors and Thyroid Cancer Risk by Histological Subtype: Pooled Analysis of 22 Prospective Studies. Thyroid 2016; 26:306-18. [PMID: 26756356 PMCID: PMC4754509 DOI: 10.1089/thy.2015.0319] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Greater height and body mass index (BMI) have been associated with an increased risk of thyroid cancer, particularly papillary carcinoma, the most common and least aggressive subtype. Few studies have evaluated these associations in relation to other, more aggressive histologic types or thyroid cancer-specific mortality. METHODS This large pooled analysis of 22 prospective studies (833,176 men and 1,260,871 women) investigated thyroid cancer incidence associated with greater height, BMI at baseline and young adulthood, and adulthood BMI gain (difference between young-adult and baseline BMI), overall and separately by sex and histological subtype using multivariable Cox proportional hazards regression models. Associations with thyroid cancer mortality were investigated in a subset of cohorts (578,922 men and 774,373 women) that contributed cause of death information. RESULTS During follow-up, 2996 incident thyroid cancers and 104 thyroid cancer deaths were identified. All anthropometric factors were positively associated with thyroid cancer incidence: hazard ratios (HR) [confidence intervals (CIs)] for height (per 5 cm) = 1.07 [1.04-1.10], BMI (per 5 kg/m2) = 1.06 [1.02-1.10], waist circumference (per 5 cm) = 1.03 [1.01-1.05], young-adult BMI (per 5 kg/m2) = 1.13 [1.02-1.25], and adulthood BMI gain (per 5 kg/m2) = 1.07 [1.00-1.15]. Associations for baseline BMI and waist circumference were attenuated after mutual adjustment. Baseline BMI was more strongly associated with risk in men compared with women (p = 0.04). Positive associations were observed for papillary, follicular, and anaplastic, but not medullary, thyroid carcinomas. Similar, but stronger, associations were observed for thyroid cancer mortality. CONCLUSION The results suggest that greater height and excess adiposity throughout adulthood are associated with higher incidence of most major types of thyroid cancer, including the least common but most aggressive form, anaplastic carcinoma, and higher thyroid cancer mortality. Potential underlying biological mechanisms should be explored in future studies.
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Affiliation(s)
- Cari M Kitahara
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
| | | | | | - Sabina Rinaldi
- 3 International Agency for Research on Cancer , Lyon, France
| | - Alicja Wolk
- 4 Division of Nutritional Epidemiology, Institute of Environmental Medicine; Karolinska Institutet , Stockholm, Sweden
| | - Gila Neta
- 5 Division of Cancer Control and Population Sciences; National Cancer Institute , Rockville, Maryland
| | - Hans Olov Adami
- 6 Department of Medical Epidemiology and Biostatistics; Karolinska Institutet , Stockholm, Sweden
- 7 Department of Epidemiology, Harvard School of Public Health , Boston, Massachusetts
| | - Kristin Anderson
- 8 Division of Epidemiology and Community Health, School of Public Health; University of Minnesota , Minneapolis, Minnesota
- 9 Masonic Cancer Center; University of Minnesota , Minneapolis, Minnesota
| | - Gabriella Andreotti
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
| | - Laura E Beane Freeman
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
| | - Leslie Bernstein
- 10 Division of Cancer Etiology, Department of Population Sciences, Beckman Research Institute , City of Hope, Duarte, California
| | - Julie E Buring
- 7 Department of Epidemiology, Harvard School of Public Health , Boston, Massachusetts
- 11 Division of Preventive Medicine, Department of Medicine; Brigham and Women's Hospital , Boston, Massachusetts
| | - Francoise Clavel-Chapelon
- 12 Inserm, Centre for Research in Epidemiology and Population Health (CESP), U1018, Villejuif, France Paris South University , UMRS Inserm 1018 Team 9, Villejuif, France
| | - Lisa A De Roo
- 13 Department of Global Public Health and Primary Care, University of Bergen , Bergen, Norway
- 14 Epidemiology Branch, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Yu-Tang Gao
- 15 Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China
| | - J Michael Gaziano
- 11 Division of Preventive Medicine, Department of Medicine; Brigham and Women's Hospital , Boston, Massachusetts
- 16 Division of Aging; Brigham and Women's Hospital , Boston, Massachusetts
- 17 Massachusetts Veteran's Epidemiology, Research, and Information Center, Geriatric Research Education and Clinical Center , VA Boston Healthcare System, Boston, Massachusetts
| | - Graham G Giles
- 18 Cancer Epidemiology Centre, Cancer Council Victoria , Melbourne, Australia
- 19 Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne , Carlton, Australia
| | - Niclas Håkansson
- 4 Division of Nutritional Epidemiology, Institute of Environmental Medicine; Karolinska Institutet , Stockholm, Sweden
| | | | - Vicki A Kirsh
- 21 Prevention and Cancer Control, Cancer Care Ontario , Toronto, Canada
- 22 Dalla Lana School of Public Health, University of Toronto , Toronto, Canada
| | - Martha S Linet
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
| | - Robert J MacInnis
- 18 Cancer Epidemiology Centre, Cancer Council Victoria , Melbourne, Australia
- 19 Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne , Carlton, Australia
| | - Nicola Orsini
- 4 Division of Nutritional Epidemiology, Institute of Environmental Medicine; Karolinska Institutet , Stockholm, Sweden
| | - Yikyung Park
- 23 Division of Public Health Sciences, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Alpa V Patel
- 2 Epidemiology Research Program, American Cancer Society , Atlanta, Georgia
| | - Mark P Purdue
- 24 Ontario Institute for Cancer Research , Toronto, Canada
| | - Elio Riboli
- 25 Imperial School of Public Health, Imperial College London , London, United Kingdom
| | - Kimberly Robien
- 26 Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, George Washington University , Washington, DC
| | - Thomas Rohan
- 27 Department of Epidemiology and Population Health, Albert Einstein College of Medicine , Bronx, New York
| | - Dale P Sandler
- 14 Epidemiology Branch, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Catherine Schairer
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
| | - Arthur B Schneider
- 28 Section of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago , Chicago, Illinois
| | - Howard D Sesso
- 7 Department of Epidemiology, Harvard School of Public Health , Boston, Massachusetts
- 11 Division of Preventive Medicine, Department of Medicine; Brigham and Women's Hospital , Boston, Massachusetts
- 16 Division of Aging; Brigham and Women's Hospital , Boston, Massachusetts
| | - Xiao-Ou Shu
- 29 Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine , Nashville, Tennessee
| | - Pramil N Singh
- 30 Center for Health Research, School of Public Health, Loma Linda University , Loma Linda, California
| | - Piet A van den Brandt
- 31 Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University , Maastricht, Netherlands
| | - Elizabeth Ward
- 32 Intramural Research, American Cancer Society , Atlanta, Georgia
| | - Elisabete Weiderpass
- 6 Department of Medical Epidemiology and Biostatistics; Karolinska Institutet , Stockholm, Sweden
- 33 Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway , Tromsø, Norway
- 34 Department of Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research , Oslo, Norway
- 35 Genetic Epidemiology Group, Folkälsan Research Center , Helsinki, Finland
| | - Emily White
- 36 Public Health Services Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
- 37 Department of Epidemiology, University of Washington , Seattle, Washington
| | - Yong-Bing Xiang
- 15 Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiaotong University School of Medicine , Shanghai, China
| | - Anne Zeleniuch-Jacquotte
- 38 Division of Epidemiology, Department of Population Health and NYU Cancer Institute, NYU School of Medicine , New York, New York
| | - Wei Zheng
- 29 Division of Epidemiology, Department of Medicine, Vanderbilt Epidemiology Center, Vanderbilt-Ingram Cancer Center, Vanderbilt University School of Medicine , Nashville, Tennessee
| | - Patricia Hartge
- 1 Division of Cancer Epidemiology and Genetics; National Cancer Institute , Rockville, Maryland
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Affiliation(s)
- Kiyohiko Mabuchi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA
| | - Arthur B Schneider
- Section of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, 1819 W. Polk Street, MC 640, Chicago, IL 60616, USA
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Abstract
BACKGROUND Synovial sarcomas are uncommon malignancies that mainly affect adolescents and young adults. Most arise from the deep soft tissues of the extremities, but they can occur in other parts of the body such as the lung. Synovial sarcomas after radiation therapy are rare, in contrast with other sarcomas, with only six reported cases. Secondary malignancies after radioactive iodine (RAI) therapy are also uncommon, with the most consistent evidence for hematologic malignancies. PATIENT FINDINGS We present what we believe to be the first report of a synovial sarcoma of the lung with an SS18/SSX1 translocation after RAI therapy. At age 20, the patient developed papillary thyroid cancer and later had two surgically confirmed recurrences. Over the course of her care, she received a total of about 220 mCi of RAI. At age 34, as part of an evaluation for another suspected recurrence, she had a position emission spectroscopy-computed tomography scan, and a pulmonary mass was detected. SUMMARY AND CONCLUSION Although not previously reported, this case suggests that synovial sarcomas may be a secondary malignancy after RAI therapy. The latency in this case is reasonable, the dose to the lungs was small, but in the range where radiation-related malignancy may occur, and the somatic chromosomal rearrangement could be a radiation effect.
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Affiliation(s)
- Avni Vora
- Section of Endocrinology, Diabetes, and Metabolism, College of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
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Ron E, Lubin JH, Shore RE, Mabuchi K, Modan B, Pottern LM, Schneider AB, Tucker MA, Boice JD. Thyroid Cancer after Exposure to External Radiation: A Pooled Analysis of Seven Studies. Radiat Res 2012; 178:AV43-60. [DOI: 10.1667/rrav05.1] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Balasubramaniam S, Ron E, Gridley G, Schneider AB, Brenner AV. Association between benign thyroid and endocrine disorders and subsequent risk of thyroid cancer among 4.5 million U.S. male veterans. J Clin Endocrinol Metab 2012; 97:2661-9. [PMID: 22569239 PMCID: PMC3410263 DOI: 10.1210/jc.2011-2996] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Risk factors for thyroid cancer (TC) in males are poorly understood. OBJECTIVES, SETTING, AND PARTICIPANTS: Our aim was to evaluate the relationship between history of benign thyroid and endocrine disorders and risk of TC among 4.5 million male veterans admitted to U.S. Veterans Affairs hospitals between July 1, 1969, and September 30, 1996. DESIGN We conducted a retrospective cohort study based on hospital discharge records with 1053 cases of TC. MAIN OUTCOME MEASURES We estimated relative risks (RR) and computed 95% confidence intervals (CI) for TC using time-dependent Poisson regression models. To evaluate potential ascertainment bias and/or delayed diagnosis of TC, we also analyzed RR by time between diagnosis of benign disorder and TC (<5 or ≥ 5 yr). RESULTS RR for TC were significantly elevated with many disorders and were often higher less than 5 yr compared with 5 yr or more before TC diagnosis. RR (95% CI) less than 5 yr/at least 5 yr were 67.9 (42.4-108.8)/28.9 (9.2-90.2) for thyroid adenoma, 77.8 (64.5-93.1)/25.9 (17.9-38.0) for nontoxic nodular goiter, 23.9 (13.8-41.3)/12.9 (4.8-34.4) for thyroiditis, 8.8 (6.9-11.3)/6.0 (3.8-9.6) for hypothyroidism, 6.4 (4.4-9.4)/ 2.0 (0.8-4.8) for thyrotoxicosis, and 1.2 (1.0-1.4)/1.1 (0.9-1.5) for diabetes. For some disorders, RR also significantly varied by attained age and race with younger patients and Blacks having higher RR than older patients and Whites. CONCLUSIONS We found strong associations for a history of thyroid adenoma, nodular goiter, thyroiditis, or hypothyroidism with TC in males allowing for increased surveillance/delayed diagnosis and evidence that some of these associations are modified by age and race.
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Affiliation(s)
- Sanjeeve Balasubramaniam
- Cancer Prevention Fellowship Program and Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland 20902, USA.
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Affiliation(s)
- Arthur B Schneider
- Section of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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18
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Sinnott B, Ron E, Schneider AB. Exposing the thyroid to radiation: a review of its current extent, risks, and implications. Endocr Rev 2010; 31:756-73. [PMID: 20650861 PMCID: PMC3365850 DOI: 10.1210/er.2010-0003] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 06/04/2010] [Indexed: 12/26/2022]
Abstract
Radiation exposure of the thyroid at a young age is a recognized risk factor for the development of differentiated thyroid cancer lasting for four decades and probably for a lifetime after exposure. Medical radiation exposure, however, occurs frequently, including among the pediatric population, which is especially sensitive to the effects of radiation. In the past, the treatment of benign medical conditions with external radiation represented the most significant thyroid radiation exposures. Today, diagnostic medical radiation represents the largest source of man-made radiation exposure. Radiation exposure related to the use of computerized tomography is rising exponentially, particularly in the pediatric population. There is direct epidemiological evidence of a small but significant increased risk of cancer at radiation doses equivalent to computerized tomography doses used today. Paralleling the increasing use of medical radiation is an increase in the incidence of papillary thyroid cancer. At present, it is unclear how much of this increase is related to increased detection of subclinical disease from the increased utilization of ultrasonography and fine-needle aspiration, how much is due to a true increase in thyroid cancer, and how much, if any, can be ascribed to medical radiation exposure. Fortunately, the amount of radiation exposure from medical sources can be reduced. In this article we review the sources of thyroid radiation exposure, radiation risks to the thyroid gland, strategies for reducing radiation exposure to the thyroid, and ways that endocrinologists can participate in this effort. Finally, we provide some suggestions for future research directions.
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Affiliation(s)
- Bridget Sinnott
- Section of Endocrinology, Diabetes, and Metabolism, College of Medicine, University of Illinois at Chicago, 1819 West Polk Street (MC 640), Chicago, Illinois 60612, USA
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Abstract
BACKGROUND Whether thyroid cancer is more aggressive in radiation-exposed patients is not resolved. The frequency of aggressive features in post-Chernobyl patients suggests this may be the case. Our aim was to address this question by re-examining the pattern of risk factors for recurrence of thyroid cancers found in a cohort exposed to external radiation. METHODS The study population was drawn from a cohort of 4296 people, followed since 1974, who were treated before the age of 16 with conventional external radiation for benign conditions of the head and neck between 1939 and the early 1960s. The study group consisted of 390 patients who had surgically verified thyroid cancer. Potential risk factors for recurrence were evaluated by proportional hazards analysis. RESULTS Fifty patients had recurrences an average of 8.7 years after diagnosis while the other 340 patients were followed for an average of 19.7 years. The sooner after radiation exposure the cancer occurred, the more likely it was to recur (hazard ratio, 0.96/year; 95% confidence interval [CI] 0.91-0.99). Taking into account the effect of the onset of screening in 1974, the features predictive of recurrence were younger age at the initial diagnosis (hazard ratio, 0.95/year; 95% CI, 0.91-0.99) and the size of the thyroid cancer (hazard ratio, 1.2/cm; 95% CI, 1.0-1.6). CONCLUSION Although not based on a direct comparison, we conclude that thyroid cancers following external radiation exposure are not, on average, more aggressive than other thyroid cancers. The similarity of risk factors for recurrence suggests that they should be treated and followed in the same way as non-radiation-induced thyroid cancers.
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Affiliation(s)
- Soe Naing
- Section of Endocrinology, Metabolism and Diabetes, University of Illinois at Chicago, Chicago, Illinois
- Current address: Fresno Medical Education Program, University of California, San Francisco
| | - Barbara J. Collins
- Section of Endocrinology, Metabolism and Diabetes, University of Illinois at Chicago, Chicago, Illinois
| | - Arthur B. Schneider
- Section of Endocrinology, Metabolism and Diabetes, University of Illinois at Chicago, Chicago, Illinois
- Department of Medicine, Michael Reese Hospital, Chicago, Illinois
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Schneider AB, Viana MAG, Ron E. Weighing shadows: can meta-analysis help define the risk-benefit ratio of RAI treatment for low-risk thyroid cancer patients? Thyroid 2009; 19:435-6. [PMID: 19415992 DOI: 10.1089/thy.2009.0091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Mihailescu DV, Schneider AB. Size, number, and distribution of thyroid nodules and the risk of malignancy in radiation-exposed patients who underwent surgery. J Clin Endocrinol Metab 2008; 93:2188-93. [PMID: 18381575 PMCID: PMC2435632 DOI: 10.1210/jc.2008-0055] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT The chance that a thyroid nodule is malignant is higher when there is a history of childhood radiation exposure. OBJECTIVE The objective of the study was to determine how the size of a thyroid nodule, the number of nodules, and the distribution of nodules influence the risk of cancer in irradiated patients. PATIENTS From a cohort of 4296 radiation-exposed people, we studied the 1059 that underwent thyroid surgery. DESIGN AND OUTCOMES: We studied the association between the size, number, distribution, and rank order of thyroid nodules and the chance of malignancy. RESULTS There were 612 malignant nodules in 358 patients and 2037 benign ones in 930 patients. There was no change in the risk that a nodule was malignant with increasing size (odds ratio 0.91/cm, P = 0.11) among the 1709 nodules that were 0.5 cm or greater. A solitary nodule had a similar likelihood of being malignant as a nodule that was one of several (18.8 vs. 17.3%), whereas patients with multiple nodules were more likely to have thyroid cancer than those with solitary nodules [30.7 vs. 18.7%; risk ratio 1.64 (1.27-2.13)]. Aspirating only the largest nodule would have missed 111 of the cancers (42%), whereas aspirating the two largest nodules would have missed 45 of the cases (17%), although none would have been 10 mm or greater. CONCLUSIONS In radiation-exposed patients, the following conclusions were made: 1) the likelihood that a nodule is malignant is independent of nodule number and size; 2) the likelihood of cancer is increased if more than one nodule is present; 3) evaluating the two largest nodules by fine-needle aspiration would have resulted in a significant number of cases being missed but none with large cancers; and 4) more than half of the patients with thyroid cancer had multifocal tumors.
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Affiliation(s)
- Dan V Mihailescu
- Section of Endocrinology, Diabetes, and Metabolism, College of Medicine, University of Illinois at Chicago, 1819 West Polk Street, Chicago, IL 60612, USA
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23
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Schneider AB, Ron E, Lubin J, Stovall M, Shore-Freedman E, Tolentino J, Collins BJ. Acoustic neuromas following childhood radiation treatment for benign conditions of the head and neck. Neuro Oncol 2007; 10:73-8. [PMID: 18079359 DOI: 10.1215/15228517-2007-047] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Childhood radiation exposure has been associated with an increased risk for developing several neoplasms, particularly benign and malignant thyroid tumors, but little is known about the risk of developing acoustic neuromas. The aim of this study was to confirm whether there is a risk for acoustic neuromas and, if so, to determine its magnitude and duration. We investigated the time trend and dose-response relationships for acoustic neuroma incidence in a cohort of 3,112 individuals who were irradiated as children between 1939 and 1962. Most of the patients were treated to reduce the size of their tonsils and adenoids and received substantial radiation exposure to the cerebellopontine angle, the site of acoustic neuromas. Forty-three patients developed benign acoustic neuromas, forty of them surgically resected, far in excess of what might be expected from data derived from brain tumor registries. The mean dose (+/-SD) to the cerebellopontine angle was 4.6 +/- 1.9 Gy. The relative risk per Gy was 1.14 (95% confidence interval 1.0-1.3). The earliest case occurred 20.4 years after exposure and the latest 55 years after exposure (mean 38.3 +/- 10.1 years). Our study provides support for an association between acoustic neuromas and childhood radiation exposure. Although acoustic neuromas are usually benign and often asymptomatic, many cause significant morbidity. Following childhood radiation exposure, they appear after a long latency and continue to occur many decades afterward. Any symptoms of an acoustic neuroma in a patient with a history of radiation to the head and neck area should be investigated carefully, and the threshold for employing imaging should be lowered.
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Affiliation(s)
- Arthur B Schneider
- University of Illinois College of Medicine, Section of Endocrinology, Diabetes and Metabolism, Chicago, IL 60612, USA.
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Abstract
OBJECTIVE Benign thyroid nodules are increased by radiation exposure and recurrences are common. The goal of this study was to determine the factors related to recurrence of nodular disease and the efficacy of thyroid hormone therapy in reducing them. DESIGN, SETTING, AND SUBJECTS The study population was drawn from a cohort of 4296 people treated before the age of 16 with conventional external radiation for benign conditions of the head and neck between 1939 and the early 1960s. The study group consisted of 632 subjects who had benign nodules removed surgically. At the discretion of their physicians, 426 subjects were treated with thyroid hormone after surgery, 198 were not, and in 8 subjects, thyroid hormone treatment status was unknown. MAIN OUTCOMES There were 129 (20.4%) subjects who developed new nodules during follow-up. Women had a greater risk of recurrent nodules than men (27.5% vs. 13.5%) and the rate of recurrence correlated inversely with the extent of surgery. The group who took thyroid hormone had a lower recurrence rate than the untreated group (14.2% vs. 34.2%). The risk of recurrence was reduced to 0.69 (0.47-1.01) in thyroid hormone-treated subjects, regardless of extent of surgery, and to 0.66 (0.46-0.97) when only the subjects with less than 75% of their thyroid removed were considered. CONCLUSION Thyroid hormone therapy reduced recurrences in this irradiated cohort. It should be recommended to all patients with irradiated thyroids and previous thyroid surgery.
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Affiliation(s)
- Sathya Subbiah
- University of Illinois at Chicago, Department of Medicine, Chicago, Illinois 60612, USA
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Mushkacheva G, Rabinovich E, Privalov V, Povolotskaya S, Shorokhova V, Sokolova S, Turdakova V, Ryzhova E, Hall P, Schneider AB, Preston DL, Ron E. Thyroid abnormalities associated with protracted childhood exposure to 131I from atmospheric emissions from the Mayak weapons facility in Russia. Radiat Res 2006; 166:715-22. [PMID: 17067203 DOI: 10.1667/rr0410.1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Accepted: 07/02/2006] [Indexed: 11/03/2022]
Abstract
Between 1948 and 1960, the Mayak nuclear weapons facility in Ozyorsk, Russia discharged relatively high levels of radionuclides, primarily (131)I, into the atmosphere, resulting in appreciable exposure to the residents of Ozyorsk. To evaluate the association between thyroid diseases and childhood exposure to radioiodines, we screened 894 Ozyorsk residents born between 1952 and 1953. The study population was comprised of 581 exposed individuals living in Ozyorsk during the years of heaviest exposure and 313 nonexposed individuals who moved to Ozyorsk when radiation exposure from Mayak largely had ended. The screening protocol included a patient interview, palpation of the thyroid, cervical lymph nodes and salivary glands, an ultrasound examination, and measurement of fT4, TSH and TPOAb. Twenty-eight percent of the study group was diagnosed with a thyroid abnormality. The prevalence of nodular disease was significantly higher in the exposed group (20.7%) compared with the nonexposed (14.4%) group (relative risk = 1.4, 95% CI = 1.1; 1.9). Risks were larger for solitary nodules and for nodules > or = 10 mm in diameter. Expansion of the study to increase the number of persons screened as well as detailed dose estimation would offer an unique opportunity to evaluate thyroid disease in relation to chronic exposure to radioiodines during childhood.
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Schneider AB, Sarne DH. Long-term risks for thyroid cancer and other neoplasms after exposure to radiation. ACTA ACUST UNITED AC 2006; 1:82-91. [PMID: 16929376 DOI: 10.1038/ncpendmet0022] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 08/31/2005] [Indexed: 11/08/2022]
Abstract
Radiation-related thyroid cancer continues to be a clinical concern for two reasons: the risks associated with the widespread use of radiation treatments for benign conditions in the middle of the last century persist for decades after exposure; and radiation continues to be an effective component of the treatment of several childhood malignancies. Patients who were irradiated in the head and neck area need to be evaluated for thyroid cancer, benign thyroid nodules, hyperparathyroidism, salivary-gland neoplasms and neural tumors, including acoustic neuromas. Radiation-related thyroid cancers appear to have the same clinical behavior as other thyroid cancers, but many irradiated patients are entering the age range when more aggressive neoplasms occur. In this paper, we review how to approach the clinical management of a patient with a history of radiation exposure in the thyroid area, and how to treat radiation-exposed patients who develop related neoplasms, especially thyroid cancer.
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Affiliation(s)
- Arthur B Schneider
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, Chicago 60612, USA.
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27
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Abstract
Radiation exposure at a young age is the only environmental factor known to cause thyroid cancer, predominantly of the papillary type. We have previously reported a high percentage (86.7%) of RET-positive papillary thyroid cancers in a cohort of individuals exposed to external radiation of the head and neck area before the age of 16. Recently, we and others have reported that point mutations of the BRAF gene occur with high frequency among sporadic adult papillary thyroid carcinomas, but occur at a much lower frequency in the population exposed after the Chernobyl accident. We here report that there is a similar low frequency of BRAF mutations among our cohort of those exposed to external beam radiation as children who later developed papillary thyroid cancer as adults. Samples were analyzed by mutation allele-specific amplification (MASA) for the most common T1799A mutation in exon 15 that converts amino acid 600 from valine to glutamate. In 23 cases, only 1 sample was positive. These results are further evidence that BRAF mutations, while common in sporadic adult papillary thyroid cancers, are rare events in cancers seen in subjects exposed to radiation as children.
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Affiliation(s)
- Barbara J Collins
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, Chicago, Illinois 60612, USA.
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28
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Abstract
The relationship between radiation exposure and thyroid cancer is well known, but whether all irradiated patients should have thyroid ultrasounds is unresolved. We have performed follow-up ultrasound examinations of patients in a cohort who were exposed to conventional external radiation during 1939-63 for benign conditions of the head and neck area prior to their 16th birthday. Of 54 subjects who had normal radionuclide scans in 1974-76 and were reexamined in 1996-97 by thyroid ultrasonography, 42 remained eligible and 34 agreed to participate in the present ultrasound study. After an additional 4-8 years of follow-up and using an ultrasound machine with increased resolution, we found 160 nodules (in 33 of these 34 subjects), compared with 96 nodules (in 29 of the 34 subjects) detected in the previous examination. Only four of the new nodules were > or =10 mm. Of the previously diagnosed large (> or =10 mm) nodules, four nodules in four subjects resolved; nine nodules in six subjects regressed to <10 mm; 14 nodules in 13 subjects remained at > or =10 mm. The four new large nodules appeared in four subjects, and six small nodules increased to > or =10 mm in six other subjects. The total volume of the thyroid nodules decreased in the 13 subjects on thyroid hormone (by 0.20 cm(3)) and increased in the 21 subjects who were not (by 0.34 cm(3), p < 0.05 by unpaired t-test). In summary, thyroid nodules are extremely common in irradiated subjects. Many new ones may be observed over time, but most are small and seen because of the increased resolution of ultrasound machines. Compared to patients on no medication, nodules in patients on thyroid hormone tended to regress. Since FNA of all thyroid nodules in irradiated patients is not feasible, ultrasound is useful in identifying those lesions that are growing.
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Affiliation(s)
- Dan V Mihailescu
- Section of Endocrinology and Metabolism, University of Illinois at Chicago, Chicago, Illinois 60612, USA
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Momani MS, Shore-Freedman E, Collins BJ, Lubin J, Ron E, Schneider AB. Familial concordance of thyroid and other head and neck tumors in an irradiated cohort: analysis of contributing factors. J Clin Endocrinol Metab 2004; 89:2185-91. [PMID: 15126540 DOI: 10.1210/jc.2003-031906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Relatively little is known about variations in susceptibility to the effects of radiation in the general population. We have been studying 4296 individuals exposed as children to head and neck radiation. The present study was designed to evaluate the pattern of thyroid, parathyroid, salivary, and neural tumors in irradiated siblings for evidence of heritable susceptibility factors. We also wanted to determine whether the characteristics of thyroid cancers were influenced by familial factors. The following criteria were met by 251 sibling pairs: both irradiated, both with follow-up (average, 44.3 +/- 9.4 yr; range, 9.4-59.5 yr), and both with organ-dose estimates. For each sibling pair we derived a quantitative score, taking into account the length of follow-up and known risk factors, for their concordance and used the sum of these scores to characterize the population. Whether we used thyroid cancer or all thyroid nodules as an end point, the degree of concordance did not exceed what could be explained by the length of follow-up and known risk factors. For thyroid cancer, neither the presenting characteristics nor their rates of recurrence were influenced by their concordance status. In summary, we were unable to identify familial factors that modify the strong effects of radiation exposure. There is no reason to alter the evaluation or treatment of thyroid cancer in an irradiated patient based on whether another member of the family has radiation-related tumors.
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Affiliation(s)
- Munther S Momani
- Section of Endocrinology and Metabolism, University of Illinois, Chicago, Illinois 60612, USA
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Kaplan MM, Sarne DH, Schneider AB. In search of the impossible dream? Thyroid hormone replacement therapy that treats all symptoms in all hypothyroid patients. J Clin Endocrinol Metab 2003; 88:4540-2. [PMID: 14557418 DOI: 10.1210/jc.2003-031436] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Collins BJ, Chiappetta G, Schneider AB, Santoro M, Pentimalli F, Fogelfeld L, Gierlowski T, Shore-Freedman E, Jaffe G, Fusco A. RET expression in papillary thyroid cancer from patients irradiated in childhood for benign conditions. J Clin Endocrinol Metab 2002; 87:3941-6. [PMID: 12161537 DOI: 10.1210/jcem.87.8.8748] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Both external and internal exposure to radiation have been linked to the development of papillary thyroid cancer. Rearrangement of the gene for RET tyrosine kinase and subsequent expression of this protein has also been found to occur in many papillary thyroid cancers, and with increased frequency in radiation-related cancers following the Chernobyl accident. However, little has been reported on the frequency of RET rearrangements in cancers after exposure to external radiation. We here report on RET protein immunoreactivity in paraffin-embedded thyroid samples from 30 patients with papillary thyroid cancer who received radiation treatment during childhood for benign conditions at Michael Reese Hospital in Chicago, and in 34 patients identified from the tumor registry as having papillary thyroid cancer with no history of therapeutic radiation. The subjects were characterized by sex, age at surgery, and the following attributes of tumor pathology: size, number of lobes involved, number of foci, lymph node metastases, and soft tissue invasion. Representative tissue samples were reacted with an antibody against the RET tyrosine kinase domain whose expression has been shown to correlate highly with RET/PTC rearrangements. A greater percentage of cancers positive for RET immunoreactivity was found in the radiation-exposed group (86.7% vs. 52.9%, P = 0.006). Although the mean age at surgery of the exposed group was lower than the control group, there was no correlation of positive RET immunoreactivity with the age at surgery. No characteristics of the tumors were associated with positive RET immunoreactivity. In summary, the greater incidence of RET-immunopositives in the irradiated group indicates that the expression of RET immunoreactivity is strongly associated with radiation exposure, but the prognostic significance of this is not yet clear.
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Affiliation(s)
- B J Collins
- Section of Endocrinology, University of Illinois at Chicago, Chicago, Illinois 60612, USA.
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Mihailescu D, Shore-Freedman E, Mukani S, Lubin J, Ron E, Schneider AB. Multiple neoplasms in an irradiated cohort: pattern of occurrence and relationship to thyroid cancer outcome. J Clin Endocrinol Metab 2002; 87:3236-41. [PMID: 12107231 DOI: 10.1210/jcem.87.7.8701] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We have examined the pattern of four radiation-related neoplasms in a radiation-exposed cohort of 2795 patients. They had received conventional radiation treatments for benign conditions in the head and neck area when they were children. At the end of follow-up, 350 thyroid cancers, 108 benign and malignant salivary tumors, 87 neural tumors, and 70 cases of hyperparathyroidism had occurred. In 492 individuals (17.6% of the cohort), there were single tumors, and in 60 individuals (2.1%), there were multiple tumors. Because this was an apparent excess of multiple tumors, we tested the hypothesis that the excess arose, at least in part, from variation in radiation susceptibility in the cohort. To analyze this, we developed a method to account for differences in length of follow-up and known risk factors, such as age at radiation exposure, radiation dose, and gender. This analysis showed that the excess concordance of neoplasms could be explained by known risk factors, thereby suggesting that susceptibility factors did not play a role in the development of multiple tumors. Of the 350 thyroid cancers, 50 occurred in subjects with other radiation-related neoplasms. Therefore, we tested an additional hypothesis, that the presence of these other neoplasms was related to the clinical behavior of the thyroid cancer. Using thyroid cancer recurrence as the end point, we did not observe a relationship with the presence of other neoplasms. In summary, we demonstrated an excess of concordance of radiation-related neoplasms that could be explained by known risk factors, and we found that thyroid cancer behavior was not related to the occurrence of multiple tumors.
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Affiliation(s)
- Dan Mihailescu
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, 1819 West Polk Street, Chicago, IL 60612, USA
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Bucci A, Shore-Freedman E, Gierlowski T, Mihailescu D, Ron E, Schneider AB. Behavior of small thyroid cancers found by screening radiation-exposed individuals. J Clin Endocrinol Metab 2001; 86:3711-6. [PMID: 11502800 DOI: 10.1210/jcem.86.8.7742] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Thyroid cancers detected by screening irradiated individuals are often small and of uncertain clinical significance. We retrospectively analyzed the effect of screening in a cohort of 4296 individuals exposed to radiation as children in the 1940s and 1950s and followed by us from 1974 until the present. We compared the thyroid cancers diagnosed before 1974 (122 cases, routine care) with the cancers found in subjects screened by us after 1974 (172 cases, screened), using cancer recurrence as the end point. Screening included a thyroid scan or, more recently, thyroid ultrasound. As expected, many of the cancers found by screening were very small (52% were <10 mm), but the range of tumor sizes overlapped those found by routine care. The recurrence rate was significantly lower in the cases found by screening, but when the comparison was limited to cancers 10 mm or larger, no difference in the recurrence rates was seen. This would suggest that the lower recurrence rate observed for small thyroid cancers detected at screening was due to earlier diagnosis rather than more effective treatment. By univariate analysis, four factors were associated with an increased risk of recurrence of small (<10 mm) thyroid cancers: short latency (i.e. a shorter time interval between the radiation exposure and the first thyroid surgery), lymph node metastases present at diagnosis, multifocal cancers, and higher radiation dose. In a multivariate analysis combining the four risk factors, only short latency was significant. As thyroid cancers that escape detection by routine means should be diagnosed at screening, and both large and small thyroid cancers have the potential to recur, screening may be of value, but only if groups with a sufficiently high prevalence of thyroid cancer can be identified to offset the adverse effects of unnecessary treatment due to false positive results.
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Affiliation(s)
- A Bucci
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, Chicago, Illinois 60612, USA
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Abstract
Dystroglycan is a high affinity laminin-binding glycoprotein originally described as a member of the dystrophin-associated glycoprotein complex in muscle. We have demonstrated the presence of dystroglycan in the thyroid using immunocytochemistry, immunoblots, ligand binding assays, and relative quantitative RT-PCR. In intact rat thyroid glands, antibodies against the alpha (extracellular, laminin-binding subunit) and beta (cytoplasmic/membrane bound) portions of the dystroglycan protein reacted at basolateral membranes where they colocalized with laminin. Western-blotted protein from the Fischer rat thyroid cell line FRTL-5 reacted with both the alpha- and beta-dystroglycan antibodies. The alpha-dystroglycan-reactive band colocalized with laminin-binding activity, and the protein and binding activity were decreased by TSH. In contrast, in the culture medium of these cells, alpha-dystroglycan was increased by TSH. The beta-dystroglycan antibody recognized the full-length 43-kDa band and an approximately 30-kDa truncated form. The truncated form was reduced in cells cultured with TSH, whereas the full-length form was not significantly diminished by TSH. Immunofluorescence of FRTL-5 cells in the absence of TSH showed a colocalization of dystroglycan and laminin. This was disrupted by the addition of TSH and was correlated to morphological changes. PCR amplification of complementary DNA with primer pairs from alpha- and beta-dystroglycan produced appropriately sized bands, whose sequence had identical protein-coding sequences and more than 96% nucleotide homology to mouse dystroglycan sequences. Relative quantitative RT-PCR of beta-dystroglycan messenger RNA showed reduced expression in cells cultured with TSH. We conclude that dystroglycan is present in rat thyroid and in FRTL5 rat thyroid cells and that TSH reduces its expression.
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Affiliation(s)
- B J Collins
- Section of Endocrinology and Metabolism, University of Illinois, Chicago, Illinois 60612, USA.
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Abstract
Oral iodinated radiographic contrast agents such as ipodate and iopanoic acid form an important part of the armamentarium used to treat hyperthyroidism. They rapidly and dramatically reduce serum triiodothyronine (T3) levels by inhibiting conversion of thyroxine (T4) to T3 in the periphery and by blocking secretion from the thyroid. Potential risks from the large iodine load resulting from their use limit their widespread applicability. In addition, they are ineffective when used alone on a long-term basis. However, these agents may be especially useful in treating thyrotoxic patients preoperatively, in neonatal Graves' disease, in massive levothyroxine ingestion, and when other conventional antithyroid drugs are unsuccessful or contraindicated.
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Affiliation(s)
- J C Fontanilla
- Department of Medicine, University of Illinois at Chicago, USA
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Abstract
The thyroid gland is one of the most sensitive organs for radiation-induced oncogenesis and the magnitude of the risk from external radiation is well understood. This is not the case for internal radiation derived from the radioiodines, a matter of practical importance because of medical use and potential accidental exposure. This article reviews current knowledge derived from the follow-up of patients receiving diagnostic or therapeutic 131I and populations exposed to radioactive fallout. The latter includes the nuclear power station accident at Chernobyl and the results of atomic bomb development and testing at Hanford, the Nevada Test Site and the Marshall Islands. The most cogent information comes from Chernobyl where an epidemic of childhood thyroid cancer has followed exposure to radioiodine that was mainly 131I. Although much has been learned from this experience about the nature of radioiodine induced thyroid cancer in young children, the reconstruction of thyroid radiation doses is too preliminary to provide accurate knowledge of the risk in comparison to that from external radiation. In the Marshall Islands, much of the exposure was from short-lived radioiodines as well as external radiation, obviating the possibility to determine the risk from 131I. Exposure to 131I in the continental United States from atomic bomb testing is expected to have caused some thyroid cancers, but only in the immediate vicinity of the Nevada Test Site has any evidence of radiation-induced thyroid neoplasms been adduced. This evidence is minimally significant statistically, and not significant for thyroid cancer per se. Medical use of radioiodine has not been observed to cause thyroid cancer but very few of the patients studied were young children, the group most sensitive to thyroid radiation. Despite these limitations, this information is sufficient to make some suggestions concerning protective measures in the case of nuclear accidents and the follow up of individuals who have been exposed.
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Affiliation(s)
- J Robbins
- National Institutes of Health, NIDDK, Genetics and Biochemistry Branch, Bldg 10, Rm 6C 201A, 10 Center Drive MSC 1587, Bethesda, MD 20892-1587, USA.
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Abstract
External radiation used to treat benign conditions in the head and neck area results in an increased risk of thyroid cancer in exposed individuals. Fine-needle aspiration (FNA) biopsy is the standard procedure used to evaluate suspicious thyroid nodules. Its accuracy has been extensively studied, but little is known about FNA in irradiated patients. We analyzed the FNA experience of 136 irradiated subjects. Fifty-two had surgery enabling a comparison of the histologic diagnosis with the FNA results. In these 52 patients with a total of 53 FNAs, 20 were reported as benign, 14 as follicular neoplasms, 6 as papillary cancer, and 13 as inadequate samples. Seven malignant nodules were aspirated; 4 were reported as papillary cancer, 1 was reported as benign and 2 had inadequate specimens. An additional 11 patients had thyroid cancer in foci that were not subjected to FNA. For the nodules that were aspirated, and considering an FNA report of follicular neoplasm as a false-positive when a follicular adenoma or a colloid nodule was found at surgery, the calculated sensitivity was 80%, specificity 54%, positive predictive value 20%, and negative predictive value 95%. Of the 14 follicular neoplasm FNA diagnoses, 10 were colloid nodules (71%), and 4 only were follicular adenomas. We conclude that the sensitivity of FNA in irradiated patients is similar to what is reported for the general population. However, smaller malignant nodules are common and are not diagnosed by the FNA. Also, the FNA diagnosis of follicular neoplasm is often inaccurate and inadequate aspirations are frequent in this patient group.
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Affiliation(s)
- B A Hatipoglu
- Department of Medicine, University of Illinois College of Medicine, Chicago, USA
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Hatipoglu BA, Schneider AB. Selective endocytosis of thyroglobulin: a review of potential mechanisms for protecting newly synthesized molecules from premature degradation. Biochimie 1999; 81:549-55. [PMID: 10403189 DOI: 10.1016/s0300-9084(99)80109-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In 1976 Cortese, Schneider and Salvatore (Eur. J. Biochem. 68 (1976) 121-129) showed that the thyroid gland protects newly synthesized, iodine and hormone poor thyroglobulin from immediate degradation. Since then there has been substantial progress in understanding the mechanism by which this selectivity of degradation occurs. Thyroglobulin in the follicular lumen is internalized mainly by receptor-specific endocytosis. Recycling of immature, poorly iodinated thyroglobulin back to the follicular lumen is the pathway most likely responsible for selectivity. Since additional carbohydrate groups are added to the immature thyroglobulin, it appears that this recycling occurs via the Golgi compartment. The molecular signal for recycling most likely involves the complex carbohydrates and probably is exposed GlcNAc groups. A thyroid-specific GlcNAc receptor has been identified and cloned. Other Tg-binding sites have been identified in the thyroid, but their physiological role remains to be determined.
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Affiliation(s)
- B A Hatipoglu
- Section of Endocrinology and Metabolism, University of Illinois at Chicago, College of Medicine, 60612, USA
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Schneider AB, Lubin J, Ron E, Abrahams C, Stovall M, Goel A, Shore-Freedman E, Gierlowski TC. Salivary gland tumors after childhood radiation treatment for benign conditions of the head and neck: dose-response relationships. Radiat Res 1998; 149:625-30. [PMID: 9611101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We have investigated the dose-response relationships for the incidence of salivary gland tumors in a cohort of 2945 individuals who were irradiated as children between 1939-1962. Most of the patients were treated to reduce the size of their tonsils and adenoids. The mean dose to the salivary glands (+/-SD) was 4.2 +/- 1.7 Gy. Eighty-nine patients developed 91 salivary gland neoplasms; 22 had single malignancies, 64 had single benign neoplasms, 2 developed two separate benign neoplasms, and 1 developed a single neoplasm but did not have surgery. The majority (81 of 89) of the patients developed neoplasms in the parotid glands. Mucoepidermoid carcinomas were the most common malignancy and mixed (pleomorphic) adenomas were the most common benign neoplasm. For all salivary gland tumors, the excess relative risk per gray (ERR/Gy) was 0.82; however, the 95% confidence interval was wide (0.04, upper bound indeterminate). The trend was determined principally by benign tumors, as there was no dose-response relationship for salivary gland cancer, although there were too few cases to draw definitive conclusions. Overall, our study provides support for an association between salivary gland tumors and radiation exposure. Although most salivary gland tumors are benign and are usually readily detected, they may cause morbidity, and people who have been irradiated in the area should be monitored for their occurrence.
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Affiliation(s)
- A B Schneider
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, Chicago 60612, USA
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Schneider AB, Lubin J, Ron E, Abrahams C, Stovall M, Goel A, Shore-Freedman E, Gierlowski TC. Salivary Gland Tumors after Childhood Radiation Treatment for Benign Conditions of the Head and Neck: Dose-Response Relationships. Radiat Res 1998. [DOI: 10.2307/3579909] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
While a great deal is known about the relationship between external radiation exposure and thyroid cancer, much less is known about the oncogenic effects of internal radiation exposure from isotopes of iodine. The accident at the Chernobyl nuclear power plant released massive quantities of radioiodine isotopes into the atmosphere. The large number of ensuing thyroid cancers in exposed children leaves little doubt that these malignancies have occurred as a result of the accident. However, carefully planned epidemiological studies are needed to confirm that these are due predominantly to I-131 exposure, to determine the dose-response relationship, to monitor for continuing effects and to evaluate other contributing factors. Preliminary evidence indicates that there is a distinct pattern of somatic genetic changes in the thyroid cancers from the Chernobyl area.
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Affiliation(s)
- J Robbins
- Genetics and Biochemistry Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
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Schneider AB, Bekerman C, Leland J, Rosengarten J, Hyun H, Collins B, Shore-Freedman E, Gierlowski TC. Thyroid nodules in the follow-up of irradiated individuals: comparison of thyroid ultrasound with scanning and palpation. J Clin Endocrinol Metab 1997; 82:4020-7. [PMID: 9398706 DOI: 10.1210/jcem.82.12.4428] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In 1974 we began a prospective study of a cohort of 4296 individuals exposed to therapeutic head and neck irradiation during childhood for benign conditions. To define the role of thyroid ultrasonography in following irradiated individuals, we studied a subgroup of 54 individuals. They all had been screened between 1974-1976 and had normal thyroid scans and no palpable nodules at that time. Thyroid ultrasonography, thyroid scanning, physical examination, and serum thyroglobulin measurements were performed. One or more discrete ultrasound-detected nodules were present in 47 of 54 (87%) subjects. There were a total of 157 nodules, 40 of which were 1.0 cm or larger in largest dimension. These 40 nodules occurred in 28 (52%) of the subjects. Thirty (75%) of these 1.0-cm or larger nodules matched discrete areas of diminished uptake on corresponding thyroid scans. The 10 that did not match (false negative scans for > or = 1.0-cm nodules) were the only nodules of this size in 7 subjects. Of 11 nodules 1.5 cm or larger, only 5 were palpable. Serum thyroglobulin correlated to the number (P = 0.04; r2 = 0.10), but not the volume of the thyroid nodules (P = 0.07; r2 = 0.08). We conclude that thyroid nodules are continuing to occur and are exceedingly common in this irradiated cohort of individuals. The results confirm that thyroid ultrasonography is more sensitive than physical examination and scanning. However, thyroid ultrasound is so sensitive and nodules so prevalent that great caution is needed in interpreting the results.
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Affiliation(s)
- A B Schneider
- University of Illinois College of Medicine, Chicago 60612, USA
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44
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Affiliation(s)
- A B Schneider
- University of Illinois College of Medicine, Section of Endocrinology, Chicago 60612, USA
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45
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Sznajder L, Abrahams C, Parry DM, Gierlowski TC, Shore-Freedman E, Schneider AB. Multiple schwannomas and meningiomas associated with irradiation in childhood. Am J Ophthalmol 1997. [DOI: 10.1016/s0002-9394(14)71028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The authors examined risk factors for benign thyroid nodules and their influence on radiation effects among 544 subjects who were exposed to childhood radiation treatment for benign head and neck conditions at a Chicago, Illinois hospital during 1939-1962. In follow-up through 1991, benign thyroid nodules were diagnosed in 131 patients. The risk of benign nodules was elevated in women (relative risk (RR) = 2.2, 95% confidence interval (CI) 1.6-3.2), Jews (RR = 1.7, 95% CI 1.2-2.5), college graduates (RR = 1.8, 95% CI 1.2-2.8), and subjects whose mother had cancer (RR = 1.7, 95% CI 1.2-2.5). There were increasing trends for risk with increasing body mass index in women and decreasing height in men. Risk was increased for women who never married (RR = 3.7, 95% CI 1.6-7.3) or who never had a full-term pregnancy (RR = 2.0, 95% CI 1.1-3.3). A significant radiation dose-response relationship was observed that was not modified by sex, education, Jewish religion, or reproductive factors. The data suggest that there are genetic, life-style (including ascertainment), and hormonal factors associated with the development of benign thyroid nodules.
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Affiliation(s)
- F L Wong
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
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Sznajder L, Abrahams C, Parry DM, Gierlowski TC, Shore-Freedman E, Schneider AB. Multiple schwannomas and meningiomas associated with irradiation in childhood. Arch Intern Med 1996; 156:1873-8. [PMID: 8790083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the pattern of neural tumors (schwannomas, vestibular schwannomas [acoustic neuromas], and meningiomas) that developed in 3013 people who received radiation treatment with x-ray beam therapy for benign conditions of the head and neck area before their 16th birthday. METHODS The surgical and pathology reports and pathology slides were reviewed for all neural tumors in the cohort. Patients with more than 1 neural tumor were compared with those with 1 neural tumor and those with no neural tumors. RESULTS There were 7 patients with multiple neural tumors and 63 with single neural tumors. The distribution of tumors in these 2 groups differed. The group with multiple tumors had more spinal nerve root schwannomas, while the group with single tumors had more cranial nerve schwannomas. Six of the 7 patients did not meet the diagnostic criteria for neurofibromatosis type 2. CONCLUSIONS Our findings suggest that host factors that increase susceptibility to radiation may be involved in the development of the multiple neural tumors. Clinically, patients with multiple neural tumors who do not meet the diagnostic criteria for neurofibromatosis type 2 should be questioned about radiation exposure. If exposure is confirmed, then screening for other radiation-related tumors should be initiated.
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Affiliation(s)
- L Sznajder
- Department of Medicine, University of Illinois at Chicago, USA
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Abstract
Little is known about the role of specific oncogenes and tumor suppressor genes in radiation-induced thyroid cancer (RITC). In thyroid cancer, mutations in the p53 tumor suppressor gene have been largely confined to the more aggressive anaplastic forms. We studied point mutations in the p53 gene in 22 patients exposed in childhood to radiation in the head and neck area who later developed papillary thyroid cancers (RITC). Eighteen thyroid cancer patients without exposure to radiation, selected to match by gender and age the RITC group, were used as the control group. After histological identification, DNA was extracted from paraffin-embedded specimens. Exons 5-8 of p53 were PCR amplified and screened for mutations by single strand conformation polymorphism analysis and cycle sequencing. Four of 22 RITC patients (18%) showed missense point mutations. No missense mutations were found in the cancer control group. The missense mutations in the RITC group occurred at codon 208 in 2 patients, codon 177 in 1, and codon 217 in 1. The mutations were transitions from G to A and C to T. All patients with missense mutations were male and had lymph node involvement. Three of the 4 patients with p53 missense mutations had invasion of the cancer beyond the thyroid capsule compared to 2 of the 17 remaining RITC patients. None of the patients with p53 mutations had distant metastases or recurrence of the tumor. These results suggest that p53 gene point mutations may play a pathogenetic role in some radiation-induced, well differentiated thyroid cancers and in their local spread.
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Affiliation(s)
- L Fogelfeld
- Department of Medicine, Michael Reese Hospital and Medical Center, University of Illinois, Chicago 60616, USA
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Abstract
Radiation remains the only factor that has been shown unequivocally to cause (nonmedullary) thyroid cancer. Recent advances include the analysis of the dose-response relationship using data pooled from multiple studies. This analysis confirms that radiation-induced thyroid cancers continue to occur, with a maximum risk at approximately 30 years after exposure. Physicians asked to evaluate patients with a history of radiation exposure should attempt to estimate the dose from the history and should be familiar with the other risk factors. For some individuals, screening should include thyroid imaging, but the results of such imaging, especially with thyroid ultrasound, should be interpreted with caution. The treatment of radiation-induced thyroid cancers is based on the observation that they appear to be no more aggressive than thyroid cancers not associated with radiation. In the future, more information should emerge about the role of cancer genes and susceptibility factors in radiation-induced thyroid cancer.
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Affiliation(s)
- D Sarne
- Section of Endocrinology and Metabolism, University of Illinois College of Medicine, Chicago, USA
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Ron E, Lubin JH, Shore RE, Mabuchi K, Modan B, Pottern LM, Schneider AB, Tucker MA, Boice JD. Thyroid cancer after exposure to external radiation: a pooled analysis of seven studies. Radiat Res 1995; 141:259-77. [PMID: 7871153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The thyroid gland of children is especially vulnerable to the carcinogenic action of ionizing radiation. To provide insights into various modifying influences on risk, seven major studies with organ doses to individual subjects were evaluated. Five cohort studies (atomic bomb survivors, children treated for tinea capitis, two studies of children irradiated for enlarged tonsils, and infants irradiated for an enlarged thymus gland) and two case-control studies (patients with cervical cancer and childhood cancer) were studied. The combined studies include almost 120,000 people (approximately 58,000 exposed to a wide range of doses and 61,000 nonexposed subjects), nearly 700 thyroid cancers and 3,000,000 person years of follow-up. For persons exposed to radiation before age 15 years, linearity best described the dose response, even down to 0.10 Gy. At the highest doses (> 10 Gy), associated with cancer therapy, there appeared to be a decrease or leveling of risk. For childhood exposures, the pooled excess relative risk per Gy (ERR/Gy) was 7.7 (95% CI = 2.1, 28.7) and the excess absolute risk per 10(4) PY Gy (EAR/10(4) PY Gy) was 4.4 (95% CI = 1.9, 10.1). The attributable risk percent (AR%) at 1 Gy was 88%. However, these summary estimates were affected strongly by age at exposure even within this limited age range. The ERR was greater (P = 0.07) for females than males, but the findings from the individual studies were not consistent. The EAR was higher among women, reflecting their higher rate of naturally occurring thyroid cancer. The distribution of ERR over time followed neither a simple multiplicative nor an additive pattern in relation to background occurrence. Only two cases were seen within 5 years of exposure. The ERR began to decline about 30 years after exposure but was still elevated at 40 years. Risk also decreased significantly with increasing age at exposure, with little risk apparent after age 20 years. Based on limited data, there was a suggestion that spreading dose over time (from a few days to > 1 year) may lower risk, possibly due to the opportunity for cellular repair mechanisms to operate. The thyroid gland in children has one of the highest risk coefficients of any organ and is the only tissue with convincing evidence for risk about 1.10 Gy.
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Affiliation(s)
- E Ron
- Epidemiology and Biostatistics Program, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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