A long-term follow-up study of late-onset hypothyroidism and prognosis of hyperthyroid patients treated with radioiodine]

We performed a follow-up study of 7,325 cases of hyperthyroidism treated with radioiodine in Japan from 1953 to 1967. Of these cases, there were 1,892 which clearly had or had not received thyroid hormone substitution therapy. Based on this, the frequency, period of onset and background of patients of hypothyroidism were investigated. There was a high incidence of cases among women in their thirties who had received large doses of radioiodine. Also, consistent with previous reports, a continuous, long-term increase in hypothyroidism was recognized. There is a need to investigate the course of the disease more thoroughly. The outbreak of thyroid tumors was also investigated. No clear increase in the incidence of tumors was seen in cases that had received radioiodine therapy. An evaluation of prognosis was made to establish the anticipated mortality rate using the mortality rate of the population at large as a base for comparison. In the 2,379 cases in which there was an effective response, no significant increase in either mortality or cancer mortality was recognized in the group that received radioiodine therapy. Nor was there an increase in the mortality rate among the younger patients in the treated group. Although there was a tendency for the overall mortality to increase when large quantities of radioiodine were prescribed. There is, however, some uncertainty as to whether or not there is a direct relationship to hypothyroidism. From this standpoint, rigorous observation during the course of treatment is important as well as commencement of appropriate substitution therapy.     

Estimation of risk based on biological dosimetry for patients treated with radioiodine.

A multicentre study was undertaken to assess the cytogenetic damage to peripheral blood lymphocytes in 31 patients treated with 131I for thyrotoxicosis using the cytokinesis-blocked micronucleus assay. The results were compared to those for eight thyroid carcinoma patients using the same method. For each patient, blood samples were taken immediately before and 1 week after iodine administration. The first blood sample was divided into three fractions and each fraction was subsequently irradiated in vitro with 0, 0.5 and 1 Gy 60Co gamma rays, respectively. After blood culture for 70 h, cells were harvested, stained with Romanowsky-Giemsa and the micronuclei scored in 1000 binucleated cells. For both patient groups, a linear-quadratic dose-response curve was fitted through the data set of the first blood sample by a least squares analysis. The mean increase in micronuclei after 131I therapy (second blood sample) was fitted to this curve and the mean equivalent total body dose (ETBD) calculated. Surprisingly, in view of the large difference in administered activity between thyroid carcinoma patients and thyrotoxicosis patients, the increase in micronuclei after therapy (mean +/- S.D.: 32 +/- 30 and 32 +/- 23, respectively) and the equivalent total body dose (0.34 and 0.32 Gy, respectively) were not significantly different (P > 0.1). The small number of micronuclei induced by 131I therapy (32 +/- 29), compared with external beam radiotherapy for Hodgkin's disease (640 +/- 381) or cervix carcinoma (298 +/- 76) [1], gave a cancer mortality estimate of less than 1%. This also explains why late detrimental effects in patients after 131I treatment have not been reported in the literature.     

Outpatient management of patients with large multinodular goitres treated with fractionated radioiodine

The efficacy of fractionated out-patient radioiodine therapy in 38 patients with compressive symptoms due to long-standing large multinodular goitres was assessed. The diagnosis was established by clinical assessment in addition to technetium-99m pertechnetate thyroid scan or computed tomography scan of the thyroid and mediastinum. Oral iodine-131 therapy was administered as a 2.22 GBq (60 mCi) cumulative dose over 4 months (555 MBq per month). All patients were monitored with serum thyroid-stimulating hormone and free thyroxine (± free tri-iodothyronine) assays before the treatment and after each dose fraction. Clinical and biochemical follow-up was performed on all patients and ranged from 6 to 45 months after therapy. The patients consisted of 35 female and three male patients with a median age of 59 years (range 37–87 years). Prior to treatment 20 patients were biochemically hyperthyroid and 18 were euthyroid. Overall, 71% of patients reported a subjective improvement in compressive symptoms and 29% reported no change. Clinically assessed reduction in goitre size occurred in 92% of patients while there was no change in 8%. At 3 months of follow-up, 31% of patients had become hypothyroid and at 18 months 66% were hypothyroid. Seven hyperthyroid patients (35%) became euthyroid and 13 hyperthyroid patients (65%) became hypothyroid. Three patients who became hypothyroid experienced neck soreness (transient in one patient, persistent in two patients). There were no differences in outcome between patients who were hyperthyroid and those who were euthyroid prior to treatment. Fractionated out-patient radioiodine therapy showed excellent short- and medium-term safety, was very well tolerated and offered a satisfactory alternative treatment to surgery. Received 23 May and in revised form 11 August 1997     

Brain metastasis from differentiated thyroid cancer in patients treated with radioiodine for bone and lung lesions

Brain metastasis of differentiated thyroid cancer (DTC) often is detected during treatment of other remote lesions. We examined the prevalence, risk factors and treatment outcome of this disease encountered during nuclear medicine practice. Of the 167 patients with metastasis to lung or bone treated 1-14 times with radioactive iodine (RAI), 9 (5.4%) also had lesions in the brain. Five were males and 4 females, aged 49-84, out of the original population of 49 males and 118 females aged 10-84 (mean 54.7) years. Three of them underwent removal of their brain tumors, 5 received conventional external beam irradiation, and 2 had stereotactic radiosurgery with supervoltage X-ray. None of the brain lesions showed significant uptake of RAI despite demonstrable accumulation in most extracerebral lesions. Seven patients died 4-23 (mean 9.4) months after the discovery of cerebral metastasis, brain damage being the primary or at least a contributing cause. The 8th and 9th patients remained relatively well for more than 42 and 3 months, respectively, without any evidence of intracranial recurrence. Our results confirmed that the brain is a major site of secondary metastasis from DTC. No statistically significant demographic risk factor was detected. Any suspicious neurological symptoms in the course of RAI treatment warrant cerebral computed tomography. As for therapy, from our initial experience, radiosurgery seemed promising as an effective and less invasive alternative to surgical removal.     

Low-dose radioiodine therapy for patients with intermediate- to high-risk differentiated thyroid cancer

Annals of Nuclear Medicine - The efficacy of low-dose radioiodine therapy (RIT) for intermediate-risk or high-risk differentiated thyroid cancer (DTC) patients is controversial. Because of the...     

May smokers and overweight patients be treated with a medial open-wedge HTO? Risk factors for non-union

Purpose  

The purpose of this retrospective study was to investigate the rate of non-union after medial open-wedge high tibial osteotomy (HTO) with the Tomofix^? plate. In addition, risk factors with a possible influence on the development of a non-union were analysed.     

Readiness for return to sport in non-surgically treated patients with anterior cruciate ligament injury following a public municipal rehabilitation program

ObjectivesTo investigate the proportion of patients that pass a return to sport (RTS) test battery and assess changes in patient-reported outcomes and lower extremity muscle strength following three months of exericse-based rehabilitation in non-surgically treated patients with anterior cruciate ligament (ACL) injury.DesignProspective cohort study.SettingClinical environment (public municipal).ParticipantsThirty-nine ACL injured patients (54% female, median age (IQR) 28 years (24–35).Main outcome measuresThe Knee Injury and Osteoarthritis Outcome Score, Knee Outcome Survey Activities of Daily Living Scale, single hop for distance, crossover hop for distance, side hop test, the Agility T-test, and quadriceps and hamstrings isometric maximal voluntary contraction (MVC).ResultsFollowing 3 months of rehabilitation, patients had statistically significant improvements in all patients-reported outcomes and in quadriceps and hamstring MVC. Of 28 patients who completed all RTS tests, 11% passed six RTS criteria, 14% five criteria, 11% four criteria, 4% three criteria, 18% two criteria, 21% one criterion, and 21% none of the criteria.ConclusionsThe results suggest that three months of public municipal rehabilitation improves patient-reported outcomes and lower extremity muscle strength in non-surgically treated patients with ACL injury. However, only one in every 10 patients passed all RTS criteria.     

Follow-up of children and young adults with differentiated thyroid cancer treated with radioiodine

This is a retrospective study carried out in a group of 30 patients with differentiated thyroid cancer (age at diagnosis equal to or less than twenty years old). The aim of the study is to evaluate outcome after 131I therapy. Patients were classified into three groups on the basis of initial surgery, pathology and scintigraphic results: group I (thyroid extent), group II (locoregional extent), and group III (distant metastatic disease). Clinical parameters, 131I scans, serum thyroglobulin determinations and 131I therapeutic administered doses were evaluated in the follow-up. Some other complementary techniques such as chest X-ray and pulmonary function tests are also described. Scintigraphic absence of thyroid tissue has been observed in 83% of the cases; high thyroglobulin level is still detectable in 34% of the patients as a single evidence of disease, and 21% remain without any abnormal clinical, scintigraphic or analytical findings. Total doses administered have increased in groups I, II and III respectively, and have also been inversely proportional to the extension of lymph node surgery. At present, all the patients are alive and in good general condition. According to the results obtained, we conclude that children and young adults with DTC should undergo periodical 131I therapeutic doses in case of positive scans (once total thyroidectomy has been realized, with or without lymph node resection depending on the extension of disease). In our experience, the use of radioiodine is effective and safe in the follow-up of children and youngs with DTC.     

Papillary cancer in a patient treated with radioiodine for Graves' hyperthyroidism. Case report and a review of the risk.

A small encapsulated papillary thyroid cancer was found in a patient who had received I-131 therapy for Graves' disease 31 months previously. The relationship of Graves' hyperthyroidism and thyroid cancer is discussed, as well as the possible role of I-131 as a cause of the cancer. The published data do not support I-131 as an etiology. The patient is clinically well and cured of both hyperthyroidism and the cancer.     

Detection of breast cancer on screening mammography allows patients to be treated with less-toxic therapy

OBJECTIVE: Therapy for breast cancer is accompanied by acute and chronic toxicity. Little research has been conducted to determine the impact of the mode of breast cancer detection on the likelihood of receiving different types of treatment. The objective of this study was to determine whether detection of breast cancer on screening mammography is associated with less-toxic therapy. MATERIALS AND METHODS: The study group for this retrospective cohort study consisted of 992 women with invasive breast cancer detected on screening mammography (n = 460) or at physical examination (n = 532) at a single institution between 1990 and 2001. To address the generalizability of study findings, we compared the characteristics of study participants with those diagnosed with breast cancer in a population-based mammography registry. RESULTS: The patients whose breast cancer was detected on screening mammography more frequently had lymph nodes free of metastases (84% vs 58%, p < 0.0001), had smaller tumors (1.5 vs 2.9 cm, p < 0.0001), were more likely to be treated with breast conservation (56% vs 32%, p < 0.0001), and were less likely to be treated with chemotherapy (28% vs 56%, p < 0.0001). In a multivariate analysis with adjustments for age and functional status, patients whose cancer was detected at physical examination were more than twice as likely to undergo mastectomy (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.9-3.3) and nearly three times as likely to be treated with chemotherapy (OR, 2.9; 95% CI, 2.1-3.9). For younger women (40-49 years old), the likelihood of receiving chemotherapy was more than doubled if the cancer was detected at physical examination rather than on screening mammograms (OR, 2.3; 95% CI, 1.3-4.0). For older women (>/= 70 years old), patients whose cancer was detected at physical examination were five times more likely to undergo mastectomy (OR, 5.8; 95% CI, 3.2-10.5) and four times more likely to receive chemotherapy (OR, 4.6; 95% CI, 1.6-13) than the group whose tumors were detected on screening mammography. CONCLUSION: Breast cancers detected on screening mammography are smaller, are less likely to metastasize to lymph nodes, and are more likely to be treated with breast conservation and without chemotherapy. These findings provide an additional rationale for performing screening mammography, especially for women at age extremes for whom the survival benefit of screening mammography is debated.     

Pulmonary fibrosis in youth treated with radioiodine for juvenile thyroid cancer and lung metastases after Chernobyl

Purpose  

The objective of this project was to systematically determine the prevalence and consequences of pulmonary fibrosis in youth with thyroid carcinoma and lung metastases from Belarus who were treated with radioiodine (¹³¹I).     

Radiation exposure of the families of outpatients treated with radioiodine (iodine-131) for hyperthyroidism

Patients who receive radioiodine (iodine-131) treatment for hyperthyroidism (195–800 MBq) emit radiation and represent a potential hazard to other individuals. Critical groups amongst the public are fellow travellers on the patient’s journey home from hospital and members of the patient’s family, particularly young children. The dose which members of the public are allowed to receive as a result of a patient’s treatment has been reduced in Europe following recently revised recommendations from ICRP. The annual public dose limit is 1 mSv, though adult members of the patient’s family are allowed to receive higher doses, with the proviso that a limit of 5 mSv should not be exceeded over 5 years. Unless the doses received during out-patient administration of radioiodine can be demonstrated to comply with these new limits, hospitalisation of patients will be necessary. The radiation doses received by family members (35 adults and 87 children) of patients treated with radioiodine at five UK hospitals were measured using thermoluminescent dosimeters mounted in wrist bands. Families were given advice (according to current practice) from their treatment centre about limiting close contact with the patient for a period of time after treatment. Doses measured over 3–6 weeks were adjusted to give an estimate of values which might have been expected if the dosimeters had been worn indefinitely. Thirty-five passengers accompanying patients home after treatment also recorded the dose received during the journey using electronic (digital) personal dosimeters. For the ”adjusted” doses to infinity, 97% of adults complied with a 5-mSv dose limit (range:0.2–5.8 mSv) and 89% of children with a 1-mSv limit (range: 0.2–7.2 mSv). However 6 of 17 children aged 3 years or less had an adjusted dose which exceeded this 1 mSv limit. The dose received by adults during travel was small in comparison with the total dose received. The median travel dose was 0.03 mSv for 1 h travel (range: 2 μSv-0.52 mSv for 1 h of travel time). These data suggest that hyperthyroid patients can continue to be treated with radioiodine on an out-patient basis, if given appropriate radiation protection advice. However, particular consideration needs to be given to children aged 3 years or younger. Admission to hospital is not warranted on radiation protection grounds. Received 31 December 1998 and in revised form 20 March 1999     

The evaluation of radioiodine therapy for thyroid patients using a fixed-dose regime

Ninety-six patients with toxic diffuse goitre (Grave's disease) in whom rapid control of disease was necessary were treated with an "ablative" dose of 550 MBq of radioiodine (131I) with the intention of inducing hypothyroidism. Outcome was established in 93 cases (mean follow-up 37 months), 45 patients (48%) becoming hypothyroid, 30 (32%) remaining euthyroid and 18 (19%) with persistent thyrotoxicosis requiring further 131I therapy. It is thus apparent that a fixed dose of 550 MBq 131I cannot be considered ablative, with less than 50% of patients developing hypothyroidism.     

Contribution of computerized tomography to the diagnosis of patients with non-calcified solitary pulmonary nodule, without known neoplasm]

We define a solitary pulmonary noncalcified nodule (NPS) as a single focal rounded or ovoid lesion in the lung parenchyma, less than 4 cm in diameter, without associated adenopathy, atelectasis or pneumonia. An NPS, in the absence of a known primary malignancy, can be lung cancer (NPSM), a metastasis of unknown origin (NPSMT), or a benign lesion (NPSB). The best approach to the management of NPS and the value of CT are still controversial and uncertain. The finding on cross-section CT of a bronchus leading directly to, or contained within, the nodule is called "positive CT bronchus sign" (CT-BS). Our study was aimed at investigating the usefulness of CT bronchus sign, as studied on thin-slice (2 mm thick) CT sections, in order to establish the most appropriate diagnostic sequence in patients with solitary noncalcified pulmonary nodules (NPS). We evaluated 47 NPS (9 NPSB, 34 NPSM and 4 NPSMT) with thin-slice CT to detect the presence of CT bronchus sign. Seventeen cases had CT-BS (15 NPSM; 1 NPSB; 1 NPSMT); of them, 13 were diagnosed by means of transbronchial biopsy and brushing (TBB). Only one case (NPSM) of the 30 (19 NPSM; 3 NPSMT; 8 NPSB) without CT-BS, was diagnosed by TBB. TBB was negative in the 9 NPSB. The CT-BS is not pathognomonic of malignancy; in fact, the sign was observed in NPSB (one tuberculoma) too. Our results suggest that the CT bronchus sign is valuable in predicting the success of TBB in malignant solitary pulmonary nodules. On the other hand, it seems to be useless for NPSB. Therefore, to establish the most appropriate diagnostic sequence, thin-section CT should be performed in each patient with peripheral noncalcified lung lesions to plan whether TBB or transthoracic needle aspiration should come next. If biopsy results are poor, either surgery or the "wait and watch for growth" approaches can be suggested. The choice can be guided by the presence of predisposing factors for cancer or infection.     

Radiation exposure of the families of outpatients treated with radioiodine (iodine-131) for hyperthyroidism.

Patients who receive radioiodine (iodine-131) treatment for hyperthyroidism (195-800 MBq) emit radiation and represent a potential hazard to other individuals. Critical groups amongst the public are fellow travellers on the patient's journey home from hospital and members of the patient's family, particularly young children. The dose which members of the public are allowed to receive as a result of a patient's treatment has been reduced in Europe following recently revised recommendations from ICRP. The annual public dose limit is 1 mSv, though adult members of the patient's family are allowed to receive higher doses, with the proviso that a limit of 5 mSv should not be exceeded over 5 years. Unless the doses received during out-patient administration of radioiodine can be demonstrated to comply with these new limits, hospitalisation of patients will be necessary. The radiation doses received by family members (35 adults and 87 children) of patients treated with radioiodine at five UK hospitals were measured using thermoluminescent dosimeters mounted in wrist bands. Families were given advice (according to current practice) from their treatment centre about limiting close contact with the patient for a period of time after treatment. Doses measured over 3-6 weeks were adjusted to give an estimate of values which might have been expected if the dosimeters had been worn indefinitely. Thirty-five passengers accompanying patients home after treatment also recorded the dose received during the journey using electronic (digital) personal dosimeters. For the "adjusted" doses to infinity, 97% of adults complied with a 5-mSv dose limit (range:0.2-5.8 mSv) and 89% of children with a 1-mSv limit (range: 0.2-7.2 mSv). However 6 of 17 children aged 3 years or less had an adjusted dose which exceeded this 1 mSv limit. The dose received by adults during travel was small in comparison with the total dose received. The median travel dose was 0.03 mSv for 1 h travel (range: 2 microSv-0.52 mSv for 1 h of travel time). These data suggest that hyperthyroid patients can continue to be treated with radioiodine on an out-patient basis, if given appropriate radiation protection advice. However, particular consideration needs to be given to children aged 3 years or younger. Admission to hospital is not warranted on radiation protection grounds.     

The challenges of radioiodine treatment for incontinent paediatric patients with complex care needs

Objective:A thyrotoxic paediatric patient with incontinence, autism and Down’s syndrome was referred for radioiodine therapy. Here, the risk assessment methodology and measures taken to deliver a legally compliant treatment that was acceptable to the family are described.Methods:Prior risk assessment indicated that the most active incontinence waste would require decay storage until it could be transported for disposal. The Health and Safety Executive (HSE) indicated that school staff would be occupationally exposed under the Ionising Radiations Regulations (2017) based on the patient’s retained activity. To avoid the need for HSE registration, it was advised that the patient’s return to school may need to be delayed slightly. Post-treatment, confirmatory waste and patient dose rate measurements were made to refine the advised time scales.Results:Domestic waste disposal resumed at 28 days. The patient recommenced schooling a few days after their school reopened after the summer break. The school underwent HSE notification.Conclusion:Careful planning allowed us to provide a safe, compliant treatment regarding waste management and occupational exposure.Advances in knowledge:Incontinent ¹³¹I outpatient treatments require detailed, patient specific waste management. The HSE considered school staff as occupationally exposed by the patient well after normal social restrictions had ended.