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Hawkins Carranza F, Guadalix Iglesias S, Luisa De Mingo Domínguez M, Martín-Arriscado Arroba C, López Álvarez B, Allo Miguel G, Martínez Díaz-Guerra G. Trabecular bone deterioration in differentiated thyroid cancer: Impact of long-term TSH suppressive therapy. Cancer Med 2020; 9:5746-5755. [PMID: 32583973 PMCID: PMC7433843 DOI: 10.1002/cam4.3200] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 01/16/2023] Open
Abstract
Background Conflicting results has been reported regard osteoporosis and fractures in patients with Differentiated Thyroid Cancer (DTC). Our objective was to evaluate the long‐term effects of TSH suppression therapy with Levothyroxine (LT4) on trabecular bone score (TBS) and bone mineral density (BMD) in females with DTC after thyroidectomy. Methods About 145 women with resected DTC and receiving long‐term TSH therapy, were stratified according to the degree of TSH suppression. Mean duration of follow‐up was 12.3 ± 6.1 years. BMD and TBS, were assessed using dual‐energy X‐ray absorptiometry (DXA) and TBS iNsight (Med‐Imaps), at baseline (1‐3 months after surgery) and at the final study visit. Results In patients stratified by duration of TSH suppression therapy (Group I, 5‐10 years; Group II, >10 years), slight increases from baseline TSH levels were observed. Significant decreases in LS‐BMD and FN‐BMD were seen in patients after >10 years. TBS values were lower in Groups I (1.289 ± 0.122) and II (1.259 ± 0.129) compared with baseline values (P = .0001, both groups). Regarding the degree of TSH suppression, TBS was significantly reduced in those with TSH < 0.1 µU/mL (P = .0086), and not in patients with TSH suppression of 0.1.‐0.5 or >0.5 µU/mL. Conclusions We found deterioration of trabecular structure in patients with DTC and TSH suppression therapy below 0.1 µU/mL and after 5‐10 years of follow‐up. Significant changes in BMD according to TSH levels were not observed. Trabecular Bone Score is a useful technique for identifying thyroid cancer patients with risk of bone deterioration.
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[The thyroid gland in old age : Physiology and pathology]. Wien Med Wochenschr 2020; 170:410-419. [PMID: 32572659 DOI: 10.1007/s10354-020-00761-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/13/2020] [Indexed: 10/24/2022]
Abstract
In healthy older people the metabolism of thyroid hormones is physiologically altered and can possibly even actively contribute to longevity. This should also be taken into consideration in the treatment of diseases of the thyroid and principally also for younger patients. For example, with progressing age comorbidities become more prevalent and especially in cardiovascular diseases, hyperthyroidism is less well tolerated, and should be treated more aggressively. Benign multinodular goiter also becomes more prevalent in old age and should be surgically treated when causing mechanical symptoms. The treatment concept for malignant diseases should be adapted to the holistic situation of the patient but principally in the same manner as in younger patients. Old and very old patients also benefit from adequate, risk-adapted treatment of thyroid gland diseases so that appropriate diagnostics and clarification are meaningful, regardless of age.
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Tribulova N, Kurahara LH, Hlivak P, Hirano K, Szeiffova Bacova B. Pro-Arrhythmic Signaling of Thyroid Hormones and Its Relevance in Subclinical Hyperthyroidism. Int J Mol Sci 2020; 21:E2844. [PMID: 32325836 PMCID: PMC7215427 DOI: 10.3390/ijms21082844] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/06/2020] [Accepted: 04/17/2020] [Indexed: 12/18/2022] Open
Abstract
A perennial task is to prevent the occurrence and/or recurrence of most frequent or life-threatening cardiac arrhythmias such as atrial fibrillation (AF) and ventricular fibrillation (VF). VF may be lethal in cases without an implantable cardioverter defibrillator or with failure of this device. Incidences of AF, even the asymptomatic ones, jeopardize the patient's life due to its complication, notably the high risk of embolic stroke. Therefore, there has been a growing interest in subclinical AF screening and searching for novel electrophysiological and molecular markers. Considering the worldwide increase in cases of thyroid dysfunction and diseases, including thyroid carcinoma, we aimed to explore the implication of thyroid hormones in pro-arrhythmic signaling in the pathophysiological setting. The present review provides updated information about the impact of altered thyroid status on both the occurrence and recurrence of cardiac arrhythmias, predominantly AF. Moreover, it emphasizes the importance of both thyroid status monitoring and AF screening in the general population, as well as in patients with thyroid dysfunction and malignancies. Real-world data on early AF identification in relation to thyroid function are scarce. Even though symptomatic AF is rare in patients with thyroid malignancies, who are under thyroid suppressive therapy, clinicians should be aware of potential interaction with asymptomatic AF. It may prevent adverse consequences and improve the quality of life. This issue may be challenging for an updated registry of AF in clinical practice. Thyroid hormones should be considered a biomarker for cardiac arrhythmias screening and their tailored management because of their multifaceted cellular actions.
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Affiliation(s)
- Narcis Tribulova
- Centre of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, 84104 Bratislava, Slovakia
| | - Lin Hai Kurahara
- Department of Cardiovascular Physiology, Faculty of Medicine, Kagawa University, Kagawa 76 0793, Japan; (L.H.K.); (K.H.)
| | - Peter Hlivak
- Department of Arrhythmias and Pacing, National Institute of Cardiovascular Diseases, Pod Krásnou Hôrkou 1, 83348 Bratislava, Slovakia;
| | - Katsuya Hirano
- Department of Cardiovascular Physiology, Faculty of Medicine, Kagawa University, Kagawa 76 0793, Japan; (L.H.K.); (K.H.)
| | - Barbara Szeiffova Bacova
- Centre of Experimental Medicine, Slovak Academy of Sciences, Institute for Heart Research, 84104 Bratislava, Slovakia
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Delitala AP, Scuteri A, Doria C. Thyroid Hormone Diseases and Osteoporosis. J Clin Med 2020; 9:jcm9041034. [PMID: 32268542 PMCID: PMC7230461 DOI: 10.3390/jcm9041034] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/24/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023] Open
Abstract
Thyroid hormones are essential for normal skeletal development and normal bone metabolism in adults but can have detrimental effects on bone structures in states of thyroid dysfunction. Untreated severe hyperthyroidism influences the degree of bone mass and increases the probability of high bone turnover osteoporosis. Subclinical hyperthyroidism, defined as low thyrotropin (TSH) and free hormones within the reference range, is a subtler disease, often asymptomatic, and the diagnosis is incidentally made during screening exams. However, more recent data suggest that this clinical condition may affect bone metabolism resulting in decreased bone mineral density (BMD) and increased risk of fracture, particularly in postmenopausal women. The main causes of exogenous subclinical hyperthyroidism are inappropriate replacement dose of thyroxin and TSH suppressive L-thyroxine doses in the therapy of benign thyroid nodules and thyroid carcinoma. Available data similarly suggest that a long-term TSH suppressive dose of thyroxin may decrease BMD and may induce an increased risk of fracture. These effects are particularly observed in postmenopausal women but are less evident in premenopausal women. Overt hypothyroidism is known to lower bone turnover by reducing both osteoclastic bone resorption and osteoblastic activity. These changes in bone metabolism would result in an increase in bone mineralization. At the moment, there are no clear data that demonstrate any relationship between BMD in adults and hypothyroidism. Despite these clinical evidences, the cellular and molecular actions of thyroid hormones on bone structures are not complete clear.
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Wang F, Sun D, Zhang N, Chen Z. The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis. Gland Surg 2020; 9:311-320. [PMID: 32420255 DOI: 10.21037/gs.2020.03.07] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Application of controlled low central venous pressure (LCVP) in liver resection growing in popularity, but its efficacy and safety are still controversial. Our objectives were to assess and compare the efficacy, feasibility, and safety of controlled LCVP in patients undergoing liver resection. Methods The PubMed, Cochrane library, and EMBASE databases were systematically searched for all the relevant studies regardless of study design. We evaluated the methodological quality of the included studies and excluded studies of poor quality. Moreover, we applied a systematic review and meta-analysis by using RevMan 5.3 software to compare the efficacy and safety of LCVP vs. standard CVP for liver resection. Outcomes included operation time, blood loss, blood infusion, fluid infusion, urinary volume, postoperative complication rates, and hospital stay. Results In total, 10 studies, involving 324 patients undergoing liver resection with controlled LCVP, were identified. Meta-analysis displayed that blood loss in the LCVP group was dramatically less than that in the control group (standard CVP group, mean difference (MD): -581.68; 95% CI: -886.32 to -277.05; P=0.0002). Moreover, blood transfusion in the LCVP group was also markedly less than that in the control group (MD: -179.16; 95% CI: -282.00 to -76.33; P=0.0006). However, there was no difference between LCVP group and control group in operation time (MD: -16.24; 95% CI: -39.56 to 7.09; P=0.17), fluid infusion (MD: -287.89; 95% CI: -1,054.47 to 478.69; P=0.46), urinary volume (MD: -26.88; 95% CI: -87.14 to 33.37; P=0.38), ALT (MD: -58.66; 95% CI: -153.81 to 36.50; P=0.23), TBIL (MD: -0.32; 95% CI: -3.93 to 3.28; P=0.86), BUN (MD: -0.13; 95% CI: -0.73 to 0.47; P=0.67), CR (MD: 1.87; 95% CI: -4.90 to 8.63; P=0.59), postoperative complication rates (MD: 0.62; 95% CI: 0.44 to 0.90; P=0.01) and hospital stay (MD: -0.61; 95% CI: -1.68 to 0.46; P=0.26). Conclusions Compared with the control, controlled LCVP showed comparable efficacy and safety for the treatment during liver resection.
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Affiliation(s)
- Feiran Wang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Dongwei Sun
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Nannan Zhang
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
| | - Zhong Chen
- Department of General Surgery, Affiliated Hospital of Nantong University, Nantong 226000, China
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Notsu M, Yamauchi M, Morita M, Nawata K, Sugimoto T. Papillary thyroid carcinoma is a risk factor for severe osteoporosis. J Bone Miner Metab 2020; 38:264-270. [PMID: 31664535 DOI: 10.1007/s00774-019-01053-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/06/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Thyroid-stimulating hormone (TSH)-suppressive therapy is recommended after surgical treatment in high-risk papillary thyroid carcinoma (PTC) patients. TSH-suppressive therapy is a known risk factor for osteoporosis and fractures. However, whether patients with PTC themselves are at a higher risk of osteoporosis than healthy individuals remains unclear. This study aimed to clarify whether PTC is a risk factor for osteoporosis. MATERIALS AND METHODS Serum and urinary biochemical parameters, bone mineral density (BMD), and presence of vertebral fractures (VFs) and non-VFs were evaluated in 35 PTC patients and 35 age- and sex-matched healthy individuals. We compared the parameters between PTC and control subjects and performed multiple logistic regression analyses after adjustments for variables. RESULTS Patients with PTC had higher body mass index (BMI) and hemoglobin (Hb)A1c, as well as lower eGFR and intact PTH than controls (p < 0.05, each). There were no significant differences in the prevalence of osteoporosis and VFs and non-VFs between patients with PTC and controls. However, the prevalence of severe osteoporosis diagnosed according to WHO criteria was significantly higher in PTC subjects (34.3%) than in controls (11.4%, p < 0.05). Multivariate logistic regression analyses adjusted for age, BMI, eGFR and HbA1c identified PTC as being associated with the presence of severe osteoporosis (odds ratio, 4.20; 95% confidence interval, 1.05-16.8; p < 0.05). CONCLUSIONS We identified PTC as a risk factor for severe osteoporosis, independent of BMI, renal function and glucose profile.
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Affiliation(s)
- Masakazu Notsu
- Department of Internal Medicine 1, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan.
| | - Mika Yamauchi
- Department of Internal Medicine 1, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Miwa Morita
- Department of Internal Medicine 1, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
| | - Kiyoko Nawata
- Health and Nutrition, The University of Shimane, Matsue, Shimane, Japan
| | - Toshitsugu Sugimoto
- Department of Internal Medicine 1, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, Shimane, 693-8501, Japan
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Yoon JA, Lee YJ, Lee BJ, Kim IJ, Kim SJ, Pak K, Jeon YK, Kim JH, Kim JM, Kim K, Jun Shin M, Shin YB. Evaluation of changes in body composition and proinflammatory marker levels in ovariectomized rats with induced hyperthyroidism. ALL LIFE 2020. [DOI: 10.1080/26895293.2020.1727966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Jin A Yoon
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Young Joo Lee
- Department of Obstetrics and Gynecology, Biomedical Research Institute Pusan National University School of Medicine, Busan, Republic of Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - In-Joo Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine and BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Kyoungjune Pak
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Yun Kyung Jeon
- Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jeong Hun Kim
- Pusan National University Medical Research Institute, Pusan National University School of Medicine, Pusan National University, Busan, Republic of Korea
| | - Ji Min Kim
- Pusan National University Medical Research Institute, Pusan National University School of Medicine, Pusan National University, Busan, Republic of Korea
| | - Keunyoung Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Myung Jun Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Yong Beom Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Kim SY, Kim HJ, Kim SM, Chang H, Lee YS, Chang HS, Park CS. Thyroid Hormone Supplementation Therapy for Differentiated Thyroid Cancer After Lobectomy: 5 Years of Follow-Up. Front Endocrinol (Lausanne) 2020; 11:520. [PMID: 32849303 PMCID: PMC7412630 DOI: 10.3389/fendo.2020.00520] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Lobectomy with preservation of the contralateral lobe has already become the most preferred surgical method for patients with low-risk thyroid cancer. The incidence of and risk factors for the development of hypothyroidism after lobectomy for thyroid cancer remains unclear. The previous practice of levothyroxine supplementation post-thyroidectomy, to bring about thyroid stimulating hormone (TSH) suppression, had some serious side effects. This study aimed to evaluate the incidence of hypothyroidism and to identify the factors associated with hypothyroidism requiring thyroid hormone replacement. Methods: We retrospectively reviewed the charts of 256 consecutive patients with differentiated thyroid cancer treated with lobectomy at the Gangnam Severance Hospital between April and December 2014 who were followed-up for more than 5 years. Patients were evaluated using a thyroid function test at the time of outpatient visit every 6 months for the 1st year, with an annual follow-up thereafter. Results: After 5 years, 66.0% (169) of the patients needed levothyroxine supplementation to maintain euthyroid status. The incidence of hypothyroidism requiring levothyroxine supplementation increased until 3 years but showed no significant change in the 4 and 5th year. Recurrence showed no difference between the group with and without levothyroxine supplementation. The presence of thyroiditis and preoperative TSH levels were correlated with postoperative levothyroxine supplementation to maintain euthyroid status, in univariate and multivariate analyses. Conclusion: High preoperative TSH levels and/or thyroiditis indicate a significantly increased likelihood of developing hypothyroidism requiring thyroid hormone supplementation after a thyroid lobectomy. Patients with an increased risk of postoperative hypothyroidism must be aware of their risk factors and should undergo more intensive follow-ups.
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Affiliation(s)
- Soo Young Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Hee Jun Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Seok-Mo Kim
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Hojin Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Sang Lee
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Yong Sang Lee
| | - Hang-Seok Chang
- Department of Surgery, Thyroid Cancer Center, Gangnam Severance Hospital, Institute of Refractory Thyroid Cancer, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheong Soo Park
- Department of Surgery, CHA Ilsan Medical Center, Goyang-si, South Korea
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Laha D, Nilubol N, Boufraqech M. New Therapies for Advanced Thyroid Cancer. Front Endocrinol (Lausanne) 2020; 11:82. [PMID: 32528402 PMCID: PMC7257776 DOI: 10.3389/fendo.2020.00082] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 02/07/2020] [Indexed: 12/14/2022] Open
Abstract
Thyroid cancer is the most common endocrine cancer. The discovery of new biomarkers for thyroid cancer has significantly improved the understanding of the molecular pathogenesis of thyroid cancer, thus allowing more personalized treatments for patients with thyroid cancer. Most of the recently discovered targeted therapies inhibit the known oncogenic mechanisms in thyroid cancer initiation and progression such as MAPK pathway, PI3K/Akt-mTOR pathways, or VEGF. Despite the significant advances in molecular testing and the discoveries of new and promising therapeutics, effective treatments for advanced and metastatic, iodine-refractory thyroid cancer are still lacking. Here, we aim to summarize the current understanding of the genetic alterations and the dysregulated pathways in thyroid cancer and to discuss the most recent targeted therapies and immunotherapy for advanced thyroid cancer with a promising anti-tumor activity and clinical benefit.
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60
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Grani G, Ramundo V, Verrienti A, Sponziello M, Durante C. Thyroid hormone therapy in differentiated thyroid cancer. Endocrine 2019; 66:43-50. [PMID: 31617165 DOI: 10.1007/s12020-019-02051-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Abstract
Surgery-with or without postoperative radioiodine-is the standard of care for most patients with differentiated thyroid carcinoma (DTC). Thyroid hormone replacement therapy is the mainstay of long-term medical management. Patients treated with total thyroidectomy and some who undergo lobectomy alone require thyroid hormone therapy to restore euthyroidism with normal serum thyroid-stimulating hormone (TSH) levels. Because TSH acts as a growth factor for thyroid follicular cells (including those that are neoplastic), it can potentially affect the onset and/or progression of follicular-cell derived thyroid cancer. For this reason, some patients are placed on thyroid hormone therapy at doses that suppress secretion of TSH (suppression therapy). This mini-review looks at the potential benefits and risks of this practice in patients diagnosed with DTC. Aggressive TSH-suppressive therapy is of little or no benefit to the vast majority of patients with DTC. Practice guidelines, therefore, recommend a graded algorithm in which the potential benefits of suppression are weighed against the associated cardiovascular and skeletal risks. Large randomized controlled studies are needed to confirm the presumed oncological benefits of TSH-suppression and its causal role in adverse cardiac, skeletal, and quality of life effects and to assess the efficacy of TSH normalization in reversing or reducing these effects.
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Affiliation(s)
- Giorgio Grani
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Valeria Ramundo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Antonella Verrienti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marialuisa Sponziello
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cosimo Durante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
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Lee YK, Lee H, Han S, Jung H, Shin DY, Nam KH, Chung WY, Lee EJ. Association between Thyroid-Stimulating Hormone Level after Total Thyroidectomy and Hypercholesterolemia in Female Patients with Differentiated Thyroid Cancer: A Retrospective Study. J Clin Med 2019; 8:jcm8081106. [PMID: 31349714 PMCID: PMC6723726 DOI: 10.3390/jcm8081106] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 12/12/2022] Open
Abstract
Less-intense TSH suppression strategies can be used for differentiated thyroid cancer (DTC) patients with a low recurrence risk, but their metabolic outcomes are not well known. We aimed to evaluate changes in the serum cholesterol levels and the risk of hypercholesterolemia according to postoperative TSH levels in 1092 female DTC patients receiving levothyroxine after total thyroidectomy. The preoperative-to-follow-up change in total cholesterol (TC) levels in the TSH level <0.03, 0.03–0.3, 0.3–2, and 2–5 mIU/L groups was −3.69 mg/dL (p = 0.006), +0.13 mg/dL (p = 0.926), +12.46 mg/dL (p < 0.001), and +16.46 mg/dL (p < 0.001), respectively. When compared with TSH levels of 0.03–0.3 mIU/L, those of 0.3–2 mIU/L were found to be associated with hypercholesterolemia (adjusted odds ratio (AOR) = 1.86 and 5.08 for TC 200–240 and ≥240 vs. <200 mg/dL) and hyper-low-density lipoprotein (LDL)-cholesterolemia (AOR = 2.76 for LDL-cholesterol ≥160 vs. <130 mg/dL). Additionally, TSH levels of 2–5 mIU/dL were associated with hypercholesterolemia (AOR = 2.85 and 6.95 for TC 200–240 and ≥240 vs. <200 mg/dL) and hyper-LDL-cholesterolemia (AOR = 2.08 and 4.17 for LDL-cholesterol 130–159 and ≥160 mg/dL vs. <130 mg/dL). In patients with normal TSH level maintenance following thyroidectomy, TC levels markedly increased, resulting in an increased hypercholesterolemia prevalence. Metabolic derangement risk due to insufficient levothyroxine replacement should be considered in the adoption of less-intense TSH suppression strategies, postoperatively, in DTC patients.
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Affiliation(s)
- Young Ki Lee
- Center for Thyroid Cancer, National Cancer Center, Goyang 10408, Korea
| | - Hokyou Lee
- Department of Preventive Medicine, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Seunghee Han
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym Hospital, Incheon 21079, Korea
| | - Hyein Jung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Dong Yeob Shin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul 03722, Korea.
| | - Kee-Hyun Nam
- Division of Thyroid and Endocrine Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Woong Youn Chung
- Division of Thyroid and Endocrine Surgery, Department of Surgery, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Eun Jig Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul 03722, Korea
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Smallridge RC, Sangaralingham LR, Mwangi R, Kusumoto F, Van Houten H, Bernet V. Comparison of Incident Cardiovascular Event Rates Between Generic and Brand l-Thyroxine for the Treatment of Hypothyroidism. Mayo Clin Proc 2019; 94:1190-1198. [PMID: 31036352 DOI: 10.1016/j.mayocp.2018.11.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/15/2018] [Accepted: 11/01/2018] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine whether levothyroxine (L-T4) preparation (generic vs brand) affected hospitalization for cardiovascular events. PATIENTS AND METHODS We performed a retrospective analysis using a large administrative claims database, OptumLabs Data Warehouse, creating two 1-to-1 propensity score-matched cohorts initiating generic or brand L-T4. Patients were followed for a mean of 1.0±1.2 years (range, 0-9.3 years). We included 87,902 propensity score-matched patients (43,951 patients per cohort) initiating generic or brand L-T4. Variables included in matching were age, sex, race/ethnicity, residence region, selected comorbidities, and Charlson-Deyo comorbidity score. Patients with previous use of any thyroid preparation, amiodarone, or lithium were excluded. Primary outcomes were the event rates for hospitalizations for incident atrial fibrillation, myocardial infarction, congestive heart failure, or stroke. RESULTS In the generic L-T4 cohort, 35,242 (80.2%) were women and 7327 (16.7%) were 65 years of age or older; in the brand L-T4 cohort, 34,633 (78.8%) were women and 8092 (18.4%) were 65 years of age or older. We found no differences in event rates (events per 1000 person-years) for 4 outcomes comparing generic and brand L-T4 therapy: (1) atrial fibrillation (1.82 vs 2.19; hazard ratio [HR], 1.22; 95% CI, 0.90-1.65; P=.19); (2) myocardial infarction (2.12 vs 1.83; HR, 0.86; 95% CI, 0.64-1.17; P=.35); (3) congestive heart failure (2.27 vs 2.00; HR, 0.88; 95% CI, 0.66-1.18; P=.41); and (4) stroke (3.10 vs 2.38; HR, 0.77; 95% CI, 0.59-1.00; P=.05). Stratification by age group revealed no differences. CONCLUSION In patients with newly treated hypothyroidism, cardiovascular event rates were similar for generic and brand L-T4.
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Affiliation(s)
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Raphael Mwangi
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Fred Kusumoto
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Holly Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; OptumLabs, Cambridge, MA
| | - Victor Bernet
- Division of Endocrinology, Mayo Clinic, Jacksonville, FL
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Papaleontiou M, Banerjee M, Reyes-Gastelum D, Hawley ST, Haymart MR. Risk of Osteoporosis and Fractures in Patients with Thyroid Cancer: A Case-Control Study in U.S. Veterans. Oncologist 2019; 24:1166-1173. [PMID: 31164453 PMCID: PMC6738319 DOI: 10.1634/theoncologist.2019-0234] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Data on osteoporosis and fractures in patients with thyroid cancer, especially men, are conflicting. Our objective was to determine osteoporosis and fracture risk in U.S. veterans with thyroid cancer. MATERIALS AND METHODS This is a case-control study using the Veterans Health Administration Corporate Data Warehouse (2004-2013). Patients with thyroid cancer (n = 10,370) and controls (n = 10,370) were matched by age, sex, weight, and steroid use. Generalized linear mixed-effects regression model was used to compare the two groups in terms of osteoporosis and fracture risk. Next, subgroup analysis of the patients with thyroid cancer using longitudinal thyroid-stimulating hormone (TSH) was performed to determine its effect on risk of osteoporosis and fractures. Other covariates included patient age, sex, median household income, comorbidities, and steroid and androgen use. RESULTS Compared with controls, osteoporosis, but not fractures, was more frequent in patients with thyroid cancer (7.3% vs. 5.3%; odds ratio [OR], 1.33; 95% confidence interval [CI], 1.18-1.49) when controlling for median household income, Charlson/Deyo comorbidity score, and androgen use. Subgroup analysis of patients with thyroid cancer demonstrated that lower TSH (OR, 0.93; 95% CI, 0.90-0.97), female sex (OR, 4.24; 95% CI, 3.53-5.10), older age (e.g., ≥85 years: OR, 17.18; 95% CI, 11.12-26.54 compared with <50 years), and androgen use (OR, 1.63; 95% CI, 1.18-2.23) were associated with osteoporosis. Serum TSH was not associated with fractures (OR, 1.01; 95% CI, 0.96-1.07). CONCLUSION Osteoporosis, but not fractures, was more common in U.S. veterans with thyroid cancer than controls. Multiple factors may be contributory, with low TSH playing a small role. IMPLICATIONS FOR PRACTICE Data on osteoporosis and fragility fractures in patients with thyroid cancer, especially in men, are limited and conflicting. Because of excellent survival rates, the number of thyroid cancer survivors is growing and more individuals may experience long-term effects from the cancer itself and its treatments, such as osteoporosis and fractures. The present study offers unique insight on the risk for osteoporosis and fractures in a largely male thyroid cancer cohort. Physicians who participate in the long-term care of patients with thyroid cancer should take into consideration a variety of factors in addition to TSH level when considering risk for osteoporosis.
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Affiliation(s)
- Maria Papaleontiou
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Mousumi Banerjee
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah T Hawley
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA
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Biondi B, Kahaly GJ, Robertson RP. Thyroid Dysfunction and Diabetes Mellitus: Two Closely Associated Disorders. Endocr Rev 2019; 40:789-824. [PMID: 30649221 PMCID: PMC6507635 DOI: 10.1210/er.2018-00163] [Citation(s) in RCA: 232] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/15/2018] [Indexed: 12/13/2022]
Abstract
Thyroid dysfunction and diabetes mellitus are closely linked. Several studies have documented the increased prevalence of thyroid disorders in patients with diabetes mellitus and vice versa. This review critically discusses the different underlying mechanisms linking type 1 and 2 diabetes and thyroid dysfunction to demonstrate that the association of these two common disorders is unlikely a simple coincidence. We assess the current state of knowledge on the central and peripheral control of thyroid hormone on food intake and glucose and lipid metabolism in target tissues (such as liver, white and brown adipose tissue, pancreatic β cells, and skeletal muscle) to explain the mechanism linking overt and subclinical hypothyroidism to type 2 diabetes and metabolic syndrome. We also elucidate the common susceptibility genes and the pathogenetic mechanisms contributing to the autoimmune mechanism involved in the onset of type 1 diabetes mellitus and autoimmune thyroid disorders. An untreated thyroid dysfunction can impair the metabolic control of diabetic patients, and this association can have important repercussions on the outcome of both of these disorders. Therefore, we offer recommendations for the diagnosis, management, and screening of thyroid disorders in patients with diabetes mellitus, including the treatment of diabetic patients planning a pregnancy. We also discuss the major causes of failure to achieve an optimal management of thyroid dysfunction in diabetic patients and provide recommendations for assessing and treating these disorders during therapy with antidiabetic drugs. An algorithm for a correct approach of these disorders when linked is also provided.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - R Paul Robertson
- Department of Medicine, Division of Endocrinology and Metabolism, University of Washington School of Medicine, Seattle, Washington.,Department of Pharmacology, University of Washington, Seattle, Washington
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Boswijk E, Sanders KJC, Broeders EPM, de Ligt M, Vijgen GHEJ, Havekes B, Mingels AMA, Wierts R, van Marken Lichtenbelt WD, Schrauwen P, Mottaghy FM, Wildberger JE, Bucerius J. TSH suppression aggravates arterial inflammation - an 18F-FDG PET study in thyroid carcinoma patients. Eur J Nucl Med Mol Imaging 2019; 46:1428-1438. [PMID: 30859432 PMCID: PMC6533218 DOI: 10.1007/s00259-019-04292-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/13/2019] [Indexed: 11/04/2022]
Abstract
Purpose We aimed to investigate the influence of both hypothyroidism and thyroid-stimulating hormone (TSH) suppression on vascular inflammation, as assessed with 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT). Methods Ten thyroid carcinoma patients underwent an 18F-FDG PET/CT during post-thyroidectomy hypothyroidism and during thyrotropin (TSH) suppression after 131I (radioiodine) ablation therapy. We analysed the 18F-FDG uptake in the carotids, aortic arch, ascending, descending, and abdominal aorta to investigate the effects of thyroid hormone status on arterial inflammation. Target-to-background ratios (TBRs) corrected for blood pool activity were established for all arterial territories. Results were further compared to euthyroid historic control subjects. Results In general, there was a trend towards higher vascular TBRs during TSH suppression than during hypothyroidism (TBRmax all vessels = 1.6 and 1.8, respectively, p = 0.058), suggesting a higher degree of arterial inflammation. In concurrence with this, we found increased C-reactive protein (CRP) levels after levothyroxine treatment (CRP = 2.9 mg/l and 4.8 mg/l, p = 0.005). An exploratory comparison with euthyroid controls showed significant higher TBRs during TSH suppression for the carotids, aortic arch, thoracic descending aorta, and when all vascular territories were combined (TBRmaxp = 0.013, p = 0.016, p = 0.030 and p = 0.018 respectively). Conclusions Arterial inflammation is increased during TSH suppression. This finding sheds new light on the underlying mechanism of the suspected increased risk of cardiovascular disease in patients with TSH suppression. Electronic supplementary material The online version of this article (10.1007/s00259-019-04292-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ellen Boswijk
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Karin J C Sanders
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
- Department of Respiratory Medicine, School of Nutrition and Translational Research in Metabolism (NUTRIM), Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Evie P M Broeders
- Department of Family Medicine, Amsterdam University Medical Centre (Amsterdam UMC), Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Marlies de Ligt
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Guy H E J Vijgen
- Department of Surgery, Franciscus, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands
| | - Bas Havekes
- Department of Internal Medicine, Division of Endocrinology, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Alma M A Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Roel Wierts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Wouter D van Marken Lichtenbelt
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Patrick Schrauwen
- Department of Nutrition and Movement Sciences, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - Felix M Mottaghy
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Joachim E Wildberger
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands
| | - Jan Bucerius
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
- Department of Nuclear Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
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Abstract
The worldwide incidence of thyroid cancer is increasing. A third of new thyroid cancer cases are papillary thyroid microcarcinoma (PTM), which are 1 cm or less. These tumors are mostly indolent with excellent prognosis. Although thyroid surgery is the most common management option for patients with PTM, new management options demand that treatment decisions must be individualized and based on patient's preference, context, and biology. This article describes management options for PTM patients and shared decision-making as a novel method for individualizing care.
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Affiliation(s)
- Juan P Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Ian D Hay
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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Abstract
Thyroid hormone suppression therapy is designed to lower serum thyrotropin (TSH) levels using doses of thyroid hormone in excess of what would normally be required to maintain a euthyroid state. The basis of this therapy is the knowledge that TSH is a growth factor for thyroid cancer, so that lower serum TSH levels might be associated with decreased disease activity. However, clinical studies have not documented improved outcomes with TSH suppression, except in patients with the most advanced disease. Furthermore, there are a number of negative outcomes related to aggressive thyroid hormone therapy, including osteoporosis, fracture, and cardiovascular disease. Therefore, a graded approach to TSH suppression is recommended by the American Thyroid Association, based on initial risk and ongoing risk assessment.
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Affiliation(s)
- Bernadette Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Pansini 5, Naples 80131, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA.
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68
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Kim EH, Jeon YK, Pak K, Kim IJ, Kim SJ, Shin S, Kim BH, Kim SS, Lee BJ, Lee JG, Goh TS, Kim K. Effects of Thyrotropin Suppression on Bone Health in Menopausal Women with Total Thyroidectomy. J Bone Metab 2019; 26:31-38. [PMID: 30899722 PMCID: PMC6416151 DOI: 10.11005/jbm.2019.26.1.31] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/28/2019] [Accepted: 02/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background This study examined the change in the trabecular bone score (TBS), areal bone mineral density (aBMD), and osteoporosis in postmenopausal women who underwent thyrotropin (TSH)-suppressive therapy for treating papillary thyroid cancer after a total thyroidectomy procedure. Methods We evaluated 36 postmenopausal women who received a total thyroidectomy for papillary thyroid cancer and were undergoing TSH suppressive therapy with levothyroxine. Postmenopausal women (n=94) matched for age and body mass index were recruited as healthy controls. The aBMD and TBS of the lumbar spine were compared between dual energy X-ray absorptiometry (DXA) at baseline and at follow-up after an average of 4.92 years. Results There was no significant difference in the rate of diagnoses of osteoporosis, osteopenia, or normal bone status between the 2 groups during the baseline DXA evaluation. However, the TBS was significantly lower whereas aBMD did not show significant difference at the time of baseline DXA measurement (1st DXA, 1.343±0.098 vs. 1.372±0.06317, P<0.001; 2nd DXA, 1.342±0.095 vs. 1.370±0.062, P<0.001). The TBS and aBMD did not differ significantly between the initial and follow-up DXA images in both groups of TSH suppressive patients and controls. Conclusions The average value of TBS and aBMD did not significantly change during the follow-up period. The TSH suppressive therapy was revealed as not a significant factor for the progressive deterioration of bone status during long term follow-up.
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Affiliation(s)
- Eun Heui Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yun Kyung Jeon
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyoungjune Pak
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - In-Joo Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan Pusan National University Hospital, Yangsan, Korea
| | - Seunghyeon Shin
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Bo Hyun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sang Soo Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jeong-Gyu Lee
- Department of Family Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Tae Sik Goh
- Department of Orthopaedic Surgery and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Keunyoung Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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Klubo-Gwiezdzinska J, Auh S, Gershengorn M, Daley B, Bikas A, Burman K, Wartofsky L, Urken M, Dewey E, Smallridge R, Chindris AM, Kebebew E. Association of Thyrotropin Suppression With Survival Outcomes in Patients With Intermediate- and High-Risk Differentiated Thyroid Cancer. JAMA Netw Open 2019; 2:e187754. [PMID: 30707227 PMCID: PMC6484595 DOI: 10.1001/jamanetworkopen.2018.7754] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Suppression of thyrotropin (often referred to as thyroid-stimulating hormone, or TSH) with levothyroxine used in management of intermediate- and high-risk differentiated thyroid cancer (DTC) to reduce the likelihood of progression and death is based on conflicting evidence. OBJECTIVE To examine a cohort of patients with intermediate- and high-risk DTC to assess the association of thyrotropin suppression with progression-free survival (PFS) and overall survival. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a multicenter database analysis including patients from tertiary referral centers and local clinics followed up for a mean (SD) of 7.2 (5.8) years. Patients with DTC treated uniformly with total thyroidectomy and radioactive iodine between January 1, 1979, and March 1, 2015, were included. Among the 1012 patients, 145 patients were excluded due to the lack of longitudinal thyrotropin measurements. EXPOSURES Levothyroxine therapy to target thyrotropin suppression with dose adjustments based on changing thyrotropin goal. MAIN OUTCOMES AND MEASURES The primary outcome measures were overall survival and PFS. A Cox proportional hazards model was used to assess the contribution of age, sex, tumor size, histology, and lymph node and distant metastases at landmarks 1.5, 3.0, and 5.0 years. The patients were divided into 3 groups based on mean thyrotropin score before each landmark: (1) suppressed thyrotropin, (2) moderately suppressed or low-normal thyrotropin, and (3) low-normal or elevated thyrotropin. RESULTS Among 867 patients (557 [64.2%] female; mean [SD] age, 48.5 [16.5] years) treated with a median (range) cumulative dose of 151 (30-1600) mCi radioactive iodine, disease progression was observed in 293 patients (33.8%), and 34 patients (3.9%) died; thus, the study was underpowered in death events. Thyrotropin suppression was not associated with improved PFS at landmarks 1.5 (P = .41), 3.0 (P = .51), and 5.0 (P = .64) years. At 1.5 and 3.0 years, older age (hazard ratio [HR], 1.06; 95% CI, 1.03-1.08 and HR, 1.05; 95% CI, 1.01-1.08, respectively), lateral neck lymph node metastases (HR, 4.64; 95% CI, 2.00-10.70 and HR, 4.02; 95% CI, 1.56-10.40, respectively), and distant metastases (HR, 7.54; 95% CI, 3.46-16.50 and HR, 7.10; 95% CI, 2.77-18.20, respectively) were independently associated with subsequent time to progression, while at 5.0 years, PFS was shorter for patients with lateral neck lymph node metastases (HR, 3.70; 95% CI, 1.16-11.90) and poorly differentiated histology (HR, 71.80; 95% CI, 9.80-526.00). CONCLUSIONS AND RELEVANCE Patients with intermediate- and high-risk DTC might not benefit from thyrotropin suppression. This study provides the justification for a randomized trial.
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Affiliation(s)
- Joanna Klubo-Gwiezdzinska
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Marvin Gershengorn
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Brianna Daley
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Athanasios Bikas
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Kenneth Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Leonard Wartofsky
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC
| | - Mark Urken
- Institute of Head, Neck and Thyroid Cancer, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Eliza Dewey
- Institute of Head, Neck and Thyroid Cancer, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Robert Smallridge
- Department of Endocrinology and Cancer Center, Mayo Clinic, Jacksonville, Florida
| | - Ana-Maria Chindris
- Department of Endocrinology and Cancer Center, Mayo Clinic, Jacksonville, Florida
| | - Electron Kebebew
- Department of Surgery and Stanford Cancer Institute, Stanford University, Stanford, California
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Matrone A, Campopiano MC, Nervo A, Sapuppo G, Tavarelli M, De Leo S. Differentiated Thyroid Cancer, From Active Surveillance to Advanced Therapy: Toward a Personalized Medicine. Front Endocrinol (Lausanne) 2019; 10:884. [PMID: 31998228 PMCID: PMC6961292 DOI: 10.3389/fendo.2019.00884] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/03/2019] [Indexed: 12/22/2022] Open
Abstract
Differentiated thyroid cancer (DTC) is the most frequent endocrine malignancy and represents the most rapidly increasing cancer diagnosis worldwide. In the last 20 years, this increase has been mostly due to a higher detection of small papillary thyroid cancers, with doubtful effects on patients' outcome. In fact, despite this growth, cancer-related death remained stable over the years. The growing detection of microcarcinomas associated to the indolent behavior of these cancers led to the development of strategies of active surveillance in selected centers of different countries. Moreover, toward a more personalized approach in the management of DTC patients, surgical treatments became more conservative, favoring less extensive options in patients at low risk of recurrence. The rise in lobectomy in low-risk cases and the need to avoid further therapies, with controversial impact on recurrences and cancer-related death in selected intermediate risk cases, led to reconsider the use of radioiodine treatment, too. Since clinicians aim to treat different patients with different modalities, the cornerstone of DTC follow-up (i.e., thyroglobulin, thyroglobulin autoantibodies, and neck ultrasound) should be interpreted consistently with this change of paradigm. The introduction of novel molecular target therapies (i.e., tyrosine kinase inhibitors), as well as a better understanding of the mechanisms of immune checkpoint inhibitor therapies, is radically changing the management of patients with advanced DTC, in whom no treatment option was available. The aim of this review is to analyze the most recent developments of the management of DTC, focusing on several key issues: active surveillance strategies, initial treatment, dynamic risk re-stratification, and therapeutic options in advanced DTC.
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Affiliation(s)
- Antonio Matrone
- Endocrinology Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Antonio Matrone
| | - Maria Cristina Campopiano
- Endocrinology Unit 1, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alice Nervo
- Oncological Endocrinology Unit, Department of Medical Sciences, School of Medicine, Cittá della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Giulia Sapuppo
- Division of Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Martina Tavarelli
- Division of Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Simone De Leo
- Division of Endocrine and Metabolic Diseases, IRCCS, Istituto Auxologico Italiano, Milan, Italy
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Feldt-Rasmussen U, Klose M, Benvenga S. Interactions between hypothalamic pituitary thyroid axis and other pituitary dysfunctions. Endocrine 2018; 62:519-527. [PMID: 30191443 DOI: 10.1007/s12020-018-1738-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/23/2018] [Indexed: 12/16/2022]
Abstract
Central hypothyroidism is defined as low circulating free thyroxine (free T4) with inappropriately low circulating thyrotropin (TSH), in context of a hypothalamic pituitary pathology. Rare cases of idiopathic central hypothyroidism caused by a functional defect may occur, and the condition is often overlooked due to difficulty in achieving the correct diagnosis, sparse symptomatology of the condition and a high risk of misinterpretion of the biochemical changes in central hypothyroidism. Central hypothyroidism is mainly seen in patients with hypothalamic-pituitary pathology due to one of many possible aetiologies, where other hormone deficiencies often co-exist, and both the presence of other deficiencies and their replacement have a strong influence on the measurement of the thyroid-related hormones and thereby interpretation of the thyroid function variables in relation to the clinical impact of thyroid hormone substitution therapy. Conversely, lack of thyroid hormone has a similar strong influence on the interpretation of other pituitary hormone axes, as well as their replacement. Undertreating patients with central hypothyroidism may have serious metabolic consequences with a potentially increased risk of cardiovascular morbidity. The present review thus aims at describing central hypothyroidism, by an overview of interactions of hypothyroidism with other pituitary hormones, diagnosing/testing for central hypothyroidism, and focusing on consequences of undertreatment. Finally, it is mentioned how to deal with new diagnostic settings with lower a priori likelihood of hypopituitarism, particularly in view of the importance of stringent diagnostic testing in order to avoid overdiagnosing central hypothyroidism.
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Affiliation(s)
- Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark.
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, National University Hospital, Copenhagen University, Copenhagen, Denmark
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Master Program on Childhood, Adolescent and Women's Endocrine Health, University of Messina, Messina, Italy
- Interdepartmental Program of Molecular and Clinical Endocrinology, and Women's Endocrine Health, University hospital Policlinico G. Martino, Messina, Italy
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Lamartina L, Montesano T, Falcone R, Biffoni M, Grani G, Maranghi M, Ciotti L, Giacomelli L, Ramundo V, Lomonaco C, Di Gioia CR, Piernatale L, Ronga G, Durante C. IS IT WORTH SUPPRESSING TSH IN LOW- AND INTERMEDIATE-RISK PAPILLARY THYROID CANCER PATIENTS BEFORE THE FIRST DISEASE ASSESSMENT? Endocr Pract 2018; 25:165-169. [PMID: 30383494 DOI: 10.4158/ep-2018-0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Guidelines recommend thyroid-stimulating hormone (TSH) suppression before the first response to treatment assessment in papillary thyroid cancer (PTC) patients. The aim of this study was to assess the rate of structural disease (SD) in low- and intermediate-risk PTC patients according to TSH levels measured 1 year after primary treatment. METHODS A consecutive, prospective series of low- and intermediate-risk PTC patients with 3-years follow-up was collected. TSH, thyroglobulin (Tg), antithyroglobulin antibodies (TgAb), and neck ultrasonography (US) 1 and 3 years after primary treatment were analyzed. Recurrence risk and disease status at 1 year were defined according to the American Thyroid Association (ATA) guidelines and as the presence or absence of SD after 3 years. Patients were grouped according to TSH level at 1 year: group 1, TSH <0.1 μUI/mL; group 2, TSH 0.1 to 0.5 μUI/mL; group 3, 0.5 to 2 μUI/mL; and group 4 >2 μUI/mL. RESULTS This study included 263 patients (70.9% female, median age 47.2 years) of whom the risk of recurrence was low in 170 (65%), intermediate-low in 63 (24%), and intermediate-high in 30 (11%). The response to initial treatment at 1 year was excellent in 149 (57%), biochemical incomplete in 18 (7%), indeterminate in 84 (32%), and structural incomplete in 12 (4%). Group 1 consisted of 53 (20%) patients, group 2 of 85 (32%), group 3 of 61 (23%), and group 4 of 64 (24%). The rate of SD at 1 and 3 years from primary treatment was not significantly different between TSH groups. CONCLUSION TSH suppression before the first response to treatment assessment does not appear to influence the rate of SD evaluated 1 and 3 years after primary treatment. ABBREVIATIONS ATA = American Thyroid Association; DTC = differentiated thyroid cancer; FTC = follicular thyroid cancer; LT4 = levothyroxine; PTC = papillary thyroid cancer; SD = structural disease; Tg = thyroglobulin; TgAb = antithyroglobulin antibodies; TSH = thyroid-stimulating hormone; US = ultrasonography.
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Kim K, Kim IJ, Pak K, Kim SJ, Shin S, Kim BH, Kim SS, Lee BJ, Jeon YK. Evaluation of Bone Mineral Density Using DXA and cQCT in Postmenopausal Patients Under Thyrotropin Suppressive Therapy. J Clin Endocrinol Metab 2018; 103:4232-4240. [PMID: 29982711 DOI: 10.1210/jc.2017-02704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/15/2018] [Indexed: 02/13/2023]
Abstract
PURPOSE This study aimed to examine the discrepancy in osteoporosis diagnoses between central quantitative computed tomography (cQCT) and dual-energy X-ray absorptiometry (DXA) and evaluated correlations among volumetric bone mineral density (vBMD), areal bone mineral density (aBMD), and trabecular bone score(TBS) in postmenopausal women who were undergoing TSH suppressive therapy. METHODS We enrolled a total of 81 postmenopausal patients [median age: 58 years; interquartile range (IQR): 57 to 60 years] receiving TSH suppressive therapy with levothyroxine after undergoing total thyroidectomy for papillary thyroid cancer. Patients were diagnosed by their bone mineral density (BMD) T-score and categorized according to a vBMD threshold of 120 mg/cm3 for osteopenia and a threshold of 80 mg/cm3 for osteoporosis. RESULTS When DXA and cQCT were compared, the BMD evaluation results differed in 76% of patients (n = 62; P < 0.001), and the detection rate of osteoporosis was 30.9% for cQCT and 21.0% for DXA. Sixty-two patients had discordant results; in 46 of these patients (74%) whose DXA T-scores were normal, the diagnosis shifted to osteopenia (n = 35) and osteoporosis (n = 11) according to the vBMD on cQCT (P < 0.001), and their vBMD values were significantly correlated with TBS (r = 0.293; P = 0.008). However, aBMD was not significantly correlated with TBS (r = 0.080; P = 0.480). TBS was significantly lower in patients with osteopenia (median: 1.35; IQR: 1.18 to 1.47) and osteoporosis (median: 1.28; IQR: 1.07 to 1.47) than in those with a normal BMD value (median: 1.37; IQR: 1.25 to 1.49; P = 0.041) on cQCT. There was no significant difference in TBS according to DXA BMD status (P = 0.200). CONCLUSIONS DXA and cQCT yielded inconsistent results, and detection of osteopenia and osteoporosis was higher using cQCT. TBS showed a more significant correlation with vBMD than with aBMD.
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Affiliation(s)
- Keunyoung Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - In-Joo Kim
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Kyoungjune Pak
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine and Research Institute for Convergence of Biomedical Science and Technology, Yangsan Pusan National University Hospital, Yangsan, Republic of Korea
| | - Senghyeon Shin
- Department of Nuclear Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Bo Hyun Kim
- Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Soo Kim
- Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Byung-Joo Lee
- Department of Otorhinolaryngology ‒ Head and Neck Surgery, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Yun Kyung Jeon
- Department of Internal Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Zhang P, Xi H, Yan R. Effects of thyrotropin suppression on lumbar bone mineral density in postmenopausal women with differentiated thyroid carcinoma. Onco Targets Ther 2018; 11:6687-6692. [PMID: 30349302 PMCID: PMC6186301 DOI: 10.2147/ott.s171282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose The aim of this study was to evaluate the effect of postoperative thyroid-stimulating hormone suppression (TSHS) on bone mineral density (BMD) in Chinese postmenopausal women with differentiated thyroid carcinoma (DTC). Patients and methods A total of 225 postmenopausal women with DTC who had received TSHS were included in the study. Postmenopausal women with postoperative DTC undergoing thyroid residual ablation or metastasis treatment between 2009 and 2015 were enrolled and followed up for 2 years. They were divided into two groups: TSHS group (median thyroid-stimulating hormone [TSH] <0.3 μIU/mL) and postmenopausal control group (median TSH >0.3 μIU/mL). Lumbar 1–4 BMD levels were measured by a dual-energy X-ray absorptiometry (DXA) at baseline and 6, 12 and 24 months. All patients had calcium and vitamin D supplementation. The diagnosis of osteopenia (−1 SD > T >−2.5 SD) and osteoporosis (T <−2.5 SD) was made according to WHO guidelines. Results Thyroid cancers included 211 papillary carcinomas and 14 follicular carcinomas. One hundred and fifty-four patients were in the TSHS group, and 71 patients were in the non-suppressed TSH group (postmenopausal controls). No significant differences were found in the BMD of the lumbar spine between baseline and after 6, 12 and 24 months, pre and post treatment in TSHS and non-suppressed TSH patients. Compared with pre-TSHS, there was a reduction in the BMD of 1.9% in the lumbar spine at the 2-year follow-up. Significant difference in the number of osteopenia and osteoporosis patients at 24 months (χ2=2.88, P=0.004) was found between the TSHS (103/152) and postmenopausal control (32/68) groups. TSHS is not a significant risk of bone loss, but it is the incidence of osteopenia in postmenopausal women with DTC. Conclusion Our 2-year follow-up data indicated that TSHS had little effect on BMD in postmenopausal women with DTC. Large population with at least 5-year follow-up should be further investigated. BMD in postmenopausal women with DTC should be followed up regularly.
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Affiliation(s)
- Pei Zhang
- Department of Endocrinology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Hui Xi
- Department of Oncology, Liaocheng People's Hospital, Liaocheng, Shandong, China,
| | - Ruihong Yan
- Department of Nuclear Medicine, Liaocheng People's Hospital, Liaocheng, Shandong, China
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Kreissl MC, Janssen MJR, Nagarajah J. Current Treatment Strategies in Metastasized Differentiated Thyroid Cancer. J Nucl Med 2018; 60:9-15. [PMID: 30190306 DOI: 10.2967/jnumed.117.190819] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 09/05/2018] [Indexed: 12/21/2022] Open
Abstract
On successful completion of this activity one should be able to judge the prognosis of patients harboring metastasized differentiated thyroid cancer (DTC); identify suitable treatment regimens, taking into account the characteristics of the tumor and the patient's general condition; and know the basics of radioiodine treatment, tyrosine kinase treatment, and redifferentiation treatment for metastasized DTC.
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Affiliation(s)
- Michael C Kreissl
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Marcel J R Janssen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - James Nagarajah
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; and .,Department of Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Duisburg, Germany
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Lamartina L, Grani G, Durante C, Borget I, Filetti S, Schlumberger M. Follow-up of differentiated thyroid cancer - what should (and what should not) be done. Nat Rev Endocrinol 2018; 14:538-551. [PMID: 30069030 DOI: 10.1038/s41574-018-0068-3] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The treatment paradigm for thyroid cancer has shifted from a one-size-fits-all approach to more personalized protocols that range from active surveillance to total thyroidectomy followed by radioiodine remnant ablation. Accurate surveillance tools are available, but follow-up protocols vary widely between centres and clinicians, owing to the lack of clear, straightforward recommendations on the instruments and assessment schedule that health-care professionals should adopt. For most patients (that is, those who have had an excellent response to the initial treatment and have a low or intermediate risk of tumour recurrence), an infrequent assessment schedule is sufficient (such as a yearly determination of serum levels of TSH and thyroglobulin). Select patients will benefit from second-line imaging and more frequent assessments. This Review discusses the strengths and weaknesses of the surveillance tools and follow-up strategies that clinicians use as a function of the initial treatment and each patient's risk of recurrence.
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Affiliation(s)
- Livia Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Giorgio Grani
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Cosimo Durante
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Isabelle Borget
- Department of Biostatistic and Epidemiology, Gustave Roussy and University Paris-Saclay, Villejuif, France
| | - Sebastiano Filetti
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Rome, Italy
| | - Martin Schlumberger
- Department of Nuclear Medicine and Endocrine Oncology, Gustave Roussy and University Paris-Saclay, Villejuif, France.
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Park JH, Lee YM, Lee YH, Hong SJ, Yoon JH. The prognostic value of serum thyroid-stimulating hormone level post-lobectomy in low- and intermediate-risk papillary thyroid carcinoma. J Surg Oncol 2018; 118:390-396. [PMID: 30114333 DOI: 10.1002/jso.25164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 06/18/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study was undertaken to determine the optimal thyroid-stimulating hormone (TSH) value associated with structural recurrence in patients with low-risk or intermediate-risk papillary thyroid carcinoma (PTC) who underwent thyroid lobectomy. METHODS Patients with PTC (n = 1047) who received thyroid lobectomy and central compartment node dissection were included in the study. RESULTS Structural recurrence occurred in 42 of the patients (4.0%), and no patient died of PTC. Multivariate analysis showed a primary tumor size (with a cut-off of 0.85 cm) and serum TSH level measured 1 year after the initial surgery (cut-off 1.85 mU/L) independently predicted structural recurrence. CONCLUSIONS TSH levels during the early postoperative period need to be monitored and maintained in the lower normal range even in patients with low- or intermediate-risk PTC undergoing thyroid lobectomy.
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Affiliation(s)
- Jae Hyun Park
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Yu-Mi Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yi Ho Lee
- Department of Surgery, Hanyang University Hanmaeum Changwon Hospital, Gyeongnam, South Korea
| | - Suck Joon Hong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jong Ho Yoon
- Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
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Park J, Blackburn BE, Ganz PA, Rowe K, Snyder J, Wan Y, Deshmukh V, Newman M, Fraser A, Smith K, Herget K, Kirchhoff AC, Abraham D, Kim J, Monroe M, Hashibe M. Risk Factors for Cardiovascular Disease Among Thyroid Cancer Survivors: Findings From the Utah Cancer Survivors Study. J Clin Endocrinol Metab 2018; 103:2468-2477. [PMID: 29850817 PMCID: PMC6915829 DOI: 10.1210/jc.2017-02629] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/25/2018] [Indexed: 12/16/2022]
Abstract
CONTEXT Thyroid cancer survivors are at high risk of developing multiple cardiac and vascular conditions as consequence of cancer diagnosis and treatment. However, it is still unclear how the baseline and prognostic factors, as well as cancer treatments, play a role in increasing cardiac and vascular disease risk among thyroid cancer survivors. OBJECTIVE To investigate the association between potential risk factors, treatment effects, and cardiovascular disease (CVD) outcomes in thyroid cancer survivors. DESIGN, SETTING, PATIENTS Primary thyroid cancer survivors, diagnosed from 1997 to 2012 (n = 3822), were identified using the statewide Utah Population Database. The medical records were used to ascertain information on risk factors and CVD outcomes. Cox proportional hazards models were used to assess the risk of CVD with baseline demographic data and clinical factors. RESULTS Among thyroid cancer survivors, age and year at cancer diagnosis, cancer stage, sex, baseline body mass index, baseline comorbidities, and TSH suppression therapy were significantly associated with CVD risk 1 to 5 years after cancer diagnosis. Patients who were male, overweight or obese, older at cancer diagnosis, and diagnosed with cancer since 2005 had an increased risk of CVD compared with patients who were female, had a normal body mass index, were younger at cancer diagnosis, and diagnosed with cancer from 1997 to 1999. Administration of TSH suppression therapy, distant metastases at cancer diagnosis, and a higher Charlson comorbidity index score were associated with an increased CVD risk among thyroid cancer survivors. CONCLUSIONS Our findings suggest that examining the effect of thyroid cancer diagnosis, cancer treatment, and demographic characteristics on the risk of CVD is critical.
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Affiliation(s)
- Jihye Park
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Brenna E Blackburn
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Patricia A Ganz
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Kerry Rowe
- Intermountain Healthcare, Salt Lake City, Utah
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, Utah
| | - Yuan Wan
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | | | - Michael Newman
- Huntsman Cancer Institute, Salt Lake City, Utah
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Alison Fraser
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ken Smith
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Kim Herget
- Utah Cancer Registry, University of Utah, Salt Lake City, Utah
| | - Anne C Kirchhoff
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Dev Abraham
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Endocrinology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jaewhan Kim
- College of Health, University of Utah, Salt Lake City, Utah
| | - Marcus Monroe
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Otolaryngology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Correspondence and Reprint Requests: Mia Hashibe, PhD, Division of Public Health, Department of Family and Preventive Medicine, Huntsman Cancer Institute, 2000 Circle of Hope Drive, Salt Lake City, Utah 84112. E-mail:
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Affiliation(s)
- Bernadette Biondi
- From the Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy (B.B.); and the Division of Endocrinology, Metabolism, and Diabetes, Johns Hopkins School of Medicine, Baltimore (D.S.C.)
| | - David S Cooper
- From the Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy (B.B.); and the Division of Endocrinology, Metabolism, and Diabetes, Johns Hopkins School of Medicine, Baltimore (D.S.C.)
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Grani G, Lamartina L, Durante C, Filetti S, Cooper DS. Follicular thyroid cancer and Hürthle cell carcinoma: challenges in diagnosis, treatment, and clinical management. Lancet Diabetes Endocrinol 2018; 6:500-514. [PMID: 29102432 DOI: 10.1016/s2213-8587(17)30325-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 12/16/2022]
Abstract
Follicular thyroid cancer is the second most common differentiated thyroid cancer histological type and has been overshadowed by its more common counterpart-papillary thyroid cancer-despite its unique biological behaviour and less favourable outcomes. In this Review, we comprehensively review the literature on follicular thyroid cancer to provide an evidence-based guide to the management of these tumours, to highlight the lack of evidence behind guideline recommendations, and to identify changes and challenges over the past decades in diagnosis, prognosis, and treatment. We highlight that correct identification of cancer in indeterminate cytological samples is challenging and ultrasonographic features can be misleading. Despite certain unique aspects of follicular thyroid cancer presentation and prognosis, no specific recommendations exist for follicular thyroid cancer and Hürthle cell carcinoma in evidence-based guidelines. Efforts should be made to stimulate additional research in this field.
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Affiliation(s)
- Giorgio Grani
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Livia Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Cosimo Durante
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - Sebastiano Filetti
- Dipartimento di Medicina Interna e Specialità Mediche, University of Rome, Sapienza, Rome, Italy
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Shin DW, Suh B, Lim H, Yun JM, Song SO, Park Y. J-Shaped Association Between Postoperative Levothyroxine Dosage and Fracture Risk in Thyroid Cancer Patients: A Retrospective Cohort Study. J Bone Miner Res 2018; 33:1037-1043. [PMID: 29447437 DOI: 10.1002/jbmr.3407] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/11/2018] [Accepted: 02/08/2018] [Indexed: 11/10/2022]
Abstract
Long-term administration of supraphysiologic dosages of levothyroxine can have detrimental effect on the bone. We aimed to investigate fracture incidence among post-thyroidectomy thyroid cancer patients compared with a matched comparison group, and explore the association between levothyroxine dosage and fracture risk. From the Korean National Health Insurance database, virtually all thyroid cancer patients who received thyroidectomy in Korea from January 1, 2004 to December 31, 2012 were included. Matched subjects were selected by 1:1 propensity score matching. Cox proportional hazards regression analysis was used to determine relative risk of osteoporotic fracture. Of 185,956 thyroid cancer patients identified, fracture events were observed in 1096 subjects (0.56%) over a mean 4.35 years of follow-up. Compared to the matched comparison group, thyroid cancer patients had no elevated risk of osteoporotic fracture (hazard ratio [HR] 1.03; 95% confidence interval [CI], 0.94 to 1.12); however, the highest dosage group (≥170 μg/day) showed significantly higher risk (HR 1.25; 95% CI, 1.07 to 1.45), while the second quartile dosage group (115-144 μg/day) showed lower risk (HR 0.71; 95% CI, 0.59 to 0.84) compared to a matched comparison group. When the second quartile dosage group was considered as reference, increased fracture risk was observed in those who took either lower (first quartile: adjusted HR 1.31; 95% CI, 1.08 to 1.59) or higher dosage of levothyroxine (third quartile: adjusted HR 1.50; 95% CI, 1.26 to 1.79; fourth quartile: adjusted HR 1.79; 95% CI, 1.51 to 2.13). Thyroid cancer patients were more likely to be treated with osteoporosis medication (HR 1.22; 95% CI, 1.18 to 1.26) than the matched comparison group. Both high and low dosage of levothyroxine treatment was associated with a higher risk for fractures in a J-shaped dose-dependent manner in post-thyroidectomy patients. Future studies are needed to determine how to optimize thyroid-stimulating hormone (TSH) suppression and how to screen and manage fracture risk. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Dong Wook Shin
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Seoul, Republic of Korea
| | | | - Hyunsun Lim
- Department of Policy Research Affairs, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Jae Moon Yun
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sun Ok Song
- Division of Endocrinology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Youngmin Park
- Department of Family Medicine, National Health Insurance Service Ilsan Hospital, Goyang-si, Gyeonggi-do, Republic of Korea
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De Melo TG, Souza AL, Ficher E, Fernandes AM, Montali Da Assumpção LV, Monte Alegre S, Zantut-Wittmann DE. Reduced insulin sensitivity in differentiated thyroid cancer patients with suppressed TSH. Endocr Res 2018; 43:73-79. [PMID: 29083246 DOI: 10.1080/07435800.2017.1390673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE TSH-suppression is a therapy for thyroid cancer management, but it may lead to adverse effects, which should be balanced with its benefits. Previous studies evaluating the consequences of TSH suppression on insulin sensitivity have only been done with indirect techniques, and results were controversial. Therefore, we aimed to assess insulin sensitivity in patients with thyroid cancer and suppressed thyroid-stimulating hormone (TSH) with the most appropriate direct method (hyperinsulinemic-euglycemic clamp) in order to get a more conclusive response about the topic. METHODS A group of 20 non-obese and non-diabetic thyroid cancer patients with suppressed TSH underwent a hyperinsulinemic-euglycemic clamp to evaluate insulin sensitivity. Their results were compared to the results of a sex and body mass index (BMI) -paired control group composed of 20 healthy volunteers. RESULTS Patients were all female, aged 36.8 ± 10.2 years-old, with mean TSH 0.1 ± 0.1 μIU/mL and mean BMI 26.2 ± 3.3 kg/m2. Insulin sensitivity, determined by the insulin-stimulated glucose uptake (M-value), was lower in the patients group (4.2 ± 1.6 mg/min*kg versus 5.8 ± 1.7, age-adjusted p-value = 0.0205). CONCLUSION This study shows for the first time that subclinical thyrotoxicosis in patients with thyroid cancer is associated with insulin resistance, as measured by hyperinsulinemic-euglycemic clamp technique. Such finding may be taken into consideration by clinicians when balancing risks and benefits of TSH-suppression therapy in thyroid cancer patients.
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Affiliation(s)
- Thaís Gomes De Melo
- a Division of Endocrinology, Department of Internal Medicine , University of Campinas , Campinas , Brazil
| | - Aglecio Luiz Souza
- b Metabolic Unit, Department of Internal Medicine , University of Campinas , Campinas , Brazil
| | - Elizabeth Ficher
- a Division of Endocrinology, Department of Internal Medicine , University of Campinas , Campinas , Brazil
| | | | | | - Sarah Monte Alegre
- b Metabolic Unit, Department of Internal Medicine , University of Campinas , Campinas , Brazil
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Abstract
OBJECTIVE To establish the long term outcomes of risk stratified management of differentiated thyroid cancer (DTC). BACKGROUND Guidelines for management of DTC lack a strong evidence base and expose patients to overtreatment. This prospective study of patients diagnosed with DTC between 1977 and 2012 describes the long term outcomes of a conservative risk stratified (AMES) management policy. METHODS Outcomes were analysed around patient and tumour characteristics, primary intervention (surgery ± radioiodine (RAI)), in terms of mortality, recurrence and reintervention. RESULTS Median follow-up in 348 patients was 14 years: mean age 48 (range 10-91) years, 257 (73.9%) female, 222 (68.3%) papillary cancer, tumour size 3.4 ± 2.0 cm (mean ± SD). 89 (25.6%) AMES high risk, 116 (33.3%) TNM stage III/IV and 16 (4.6%) had distant metastases. Primary surgery comprised lobectomy in 189 (54.3%): 11 (5.8%) patients had subsequent completion total thyroidectomy with cancer present in five. Primary nodal surgery was performed in 142 (40.8%) patients. 35 (13.5%) low and 43 (48.3%) high risk patients received RAI following initial surgery. Overall disease specific survival (DSS) was 92.1% at 10 years and 90.7% at 20 years. DSS at 20 years was 99.2% in low risk cases. AMES risk scoring predicted both survival and recurrence. Patients receiving RAI and AMES high risk were significantly associated with increased risk of death and recurrence. CONCLUSIONS Routine total thyroidectomy and RAI are not justifiable for low risk DTC. Treatment should be tailored to risk and AMES risk stratification remains a simple reliable clinical tool.
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Mazziotti G, Formenti AM, Frara S, Olivetti R, Banfi G, Memo M, Maroldi R, Giubbini R, Giustina A. High Prevalence of Radiological Vertebral Fractures in Women on Thyroid-Stimulating Hormone-Suppressive Therapy for Thyroid Carcinoma. J Clin Endocrinol Metab 2018; 103:956-964. [PMID: 29121201 DOI: 10.1210/jc.2017-01986] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/01/2017] [Indexed: 02/13/2023]
Abstract
CONTEXT Bone loss and nonvertebral fractures have been reported in patients with differentiated thyroid carcinoma (DTC) undergoing thyroid-stimulating hormone (TSH) suppressive therapy. Radiological vertebral fractures (VFs) are an early and clinically crucial marker of bone fragility. OBJECTIVE AND DESIGN A cross-sectional study to evaluate the prevalence and determinants of radiological VFs in women receiving l-thyroxine (L-T4) therapy for DTC. PATIENTS AND INTERVENTIONS A total of 179 consecutive women (median age, 59 years; n = 178 postmenopausal) who had undergone thyroidectomy for DTC and were currently receiving L-T4 were evaluated for radiological VFs and bone mineral density (BMD). There were three TSH target levels [<0.5 mU/L, group 1 (n = 83); 0.5 to 1.0 mU/L, group 2 (n = 50); >1.0 mU/L, group 3 (n = 46)]. RESULTS VFs were found in 51 patients (28.5%), with significantly (P < 0.001) higher prevalence in group 1 (44.6%) as compared with group 2 (24.0%) and group 3 (4.3%). VF prevalence was not significantly different among patients in group 1 with normal BMD, osteopenia, or osteoporosis, whereas in groups 2 and 3, VFs were more frequent in patients with osteoporosis than in those with either osteopenia or normal BMD. In the whole population, VFs were significantly and independently associated with TSH level <1.0 mU/L; densitometric diagnosis of osteoporosis at lumbar spine, femoral neck, or total hip; age of patients; and duration of L-T4 therapy. CONCLUSION The prevalence of VFs was high in women with DTC who were undergoing long-term, suppressive L-T4 therapy.
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Affiliation(s)
| | - Anna Maria Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Stefano Frara
- Department of Endocrinology, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Olivetti
- Endocrine Unit, Azienda Socio-Sanitaria Territoriale, Mantua, Italy
| | - Giuseppe Banfi
- Department of Biochemistry, Vita-Salute San Raffaele University, Milan, Italy
- Laboratory of Experimental Biochemistry and Molecular Biology, I.R.C.C.S. Istituto Ortopedico Galeazzi, Milan, Italy
| | - Maurizio Memo
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Roberto Maroldi
- Department of Radiology, University of Brescia, Brescia, Italy
| | - Raffaele Giubbini
- Department of Nuclear Medicine, University of Brescia, Brescia, Italy
| | - Andrea Giustina
- Department of Endocrinology, Vita-Salute San Raffaele University, Milan, Italy
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85
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Pajamäki N, Metso S, Hakala T, Ebeling T, Huhtala H, Ryödi E, Sand J, Jukkola-Vuorinen A, Kellokumpu-Lehtinen PL, Jaatinen P. Long-term cardiovascular morbidity and mortality in patients treated for differentiated thyroid cancer. Clin Endocrinol (Oxf) 2018; 88:303-310. [PMID: 29154445 DOI: 10.1111/cen.13519] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 11/02/2017] [Accepted: 11/14/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Thyroid hormone suppression therapy has been widely used in the treatment of thyroid cancer, but concerns have been raised about the cardiovascular risks of this treatment. The objective of this study was to evaluate long-term cardiovascular morbidity and mortality in patients treated for differentiated thyroid cancer (DTC) and to assess the effect of TSH suppression and radioiodine (RAI) treatment on the cardiovascular outcome. DESIGN Retrospective cohort study. PATIENTS AND MEASUREMENTS Patients (n = 901) treated for DTC between 1981 and 2002 at 2 Finnish University hospitals were compared with a randomly chosen reference group (n = 4485) matched for age, gender and the place of residence. Kaplan-Meier and Cox regression analyses were used to estimate the risk of morbidity or death due to different cardiovascular diseases (CVD) after the diagnosis of DTC. RESULTS Morbidity due to any CVD (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.05-1.28) and due to all arrhythmias (HR 1.25, CI 1.06-1.48) and atrial fibrillation (AF) (HR 1.29, CI 1.06-1.57) was more frequent in the DTC patients than in the controls. The increased cardiovascular morbidity was confined to patients with a mean TSH level below 0.1 mU/L (HR 1.27, CI 1.03-1.58) and to those treated with RAI (HR 1.18, CI 1.05-1.31). Cardiovascular mortality, however, was lower among the patients than the controls (HR 0.73, CI 0.58-0.92), due to a lower mortality from coronary artery disease. CONCLUSIONS Differentiated thyroid cancer patients have an increased CVD morbidity, which is mostly accountable to AF and to TSH suppression below 0.1 mU/L.
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Affiliation(s)
- Nelli Pajamäki
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Tipotie Health Centre, Social and Health Services, City of Tampere, Tampere, Finland
| | - Saara Metso
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Tommi Hakala
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Tapani Ebeling
- Department of Medicine, Oulu University Hospital, Oulu, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, University of Tampere, Tampere, Finland
| | - Essi Ryödi
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Heart Center Co., Tampere University Hospital, Tampere, Finland
| | - Juhani Sand
- Päijät-Häme Central Hospital, Lahti, Finland
| | | | - Pirkko-Liisa Kellokumpu-Lehtinen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Pia Jaatinen
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
- Division of Internal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
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86
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Kim HI, Jang HW, Ahn HS, Ahn S, Park SY, Oh YL, Hahn SY, Shin JH, Kim JH, Kim JS, Chung JH, Kim TH, Kim SW. High Serum TSH Level Is Associated With Progression of Papillary Thyroid Microcarcinoma During Active Surveillance. J Clin Endocrinol Metab 2018; 103:446-451. [PMID: 29211863 DOI: 10.1210/jc.2017-01775] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 11/28/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Thyroid-stimulating hormone (TSH) is a growth factor affecting initiation or progression of papillary thyroid cancer (PTC), which supports TSH suppressive therapy in patients with PTC. In patients with papillary thyroid microcarcinoma (PTMC) during active surveillance, however, the association between serum TSH level and growth of PTMC has not been demonstrated. PATIENTS We analyzed 127 PTMCs in 126 patients under active surveillance with serial serum TSH measurement and ultrasonography. DESIGN The patients were categorized into groups with the highest, middle, and lowest time-weighted average of TSH (TW-TSH). PTMC progression was defined as a volume increase of ≥50% compared with baseline. Kaplan-Meier survival analysis according to TW-TSH groups and Cox proportional hazard modeling was performed. We identified the cutoff point for TSH level by using maximally selected log-rank statistics. RESULTS During a median follow-up of 26 months, PTMC progression was detected in 28 (19.8%) patients. Compared with the lowest TW-TSH group, the adjusted hazard ratio (HR) for PTMC progression in the highest TW-TSH group was significantly higher [HR 3.55; 95% confidence interval (CI), 1.22 to 10.28; P = 0.020], but that in the middle TW-TSH group was not (HR 1.52; 95% CI, 0.46 to 5.08; P = 0.489). The cutoff point for the serum TSH level for PTMC progression was 2.50 mU/L. CONCLUSIONS Sustained elevation of serum TSH levels during active surveillance is associated with PTMC progression. Maintaining a low-normal TSH range with levothyroxine treatment during active surveillance of PTMC might be considered in future studies.
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Affiliation(s)
- Hye In Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Department of Medical Education, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon Seon Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Soohyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - So Young Park
- Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Lyun Oh
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Yeon Hahn
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Hee Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jee Soo Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology & Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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87
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Lamartina L, Grani G, Durante C, Filetti S. Recent advances in managing differentiated thyroid cancer. F1000Res 2018; 7:86. [PMID: 29399330 PMCID: PMC5773927 DOI: 10.12688/f1000research.12811.1] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 12/11/2022] Open
Abstract
The main clinical challenge in the management of thyroid cancer is to avoid over-treatment and over-diagnosis in patients with lower-risk disease while promptly identifying those patients with more advanced or high-risk disease requiring aggressive treatment. In recent years, novel clinical and molecular data have emerged, allowing the development of new staging systems, predictive and prognostic tools, and treatment approaches. There has been a notable shift toward more conservative management of low- and intermediate-risk patients, characterized by less extensive surgery, more selective use of radioisotopes (for both diagnostic and therapeutic purposes), and less intensive follow-up. Furthermore, the histologic classification; tumor, node, and metastasis (TNM) staging; and American Thyroid Association risk stratification systems have been refined, and this has increased the number of patients in the low- and intermediate-risk categories. There is now a need for new, prospective data to clarify how these changing practices will impact long-term outcomes of patients with thyroid cancer, and new follow-up strategies and biomarkers are still under investigation. On the other hand, patients with more advanced or high-risk disease have a broader portfolio of options in terms of treatments and therapeutic agents, including multitarget tyrosine kinase inhibitors, more selective BRAF or MEK inhibitors, combination therapies, and immunotherapy.
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Affiliation(s)
- Livia Lamartina
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy
| | - Giorgio Grani
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy
| | - Cosimo Durante
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy
| | - Sebastiano Filetti
- Dipartimento di Medicina Interna e Specialità Mediche, Università di Roma "Sapienza", Viale del Policlinico 155, 00161 Rome, Italy
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88
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Giusti M, Conte L, Repetto AM, Gay S, Marroni P, Mittica M, Mussap M. Detection of Polyethylene Glycol Thyrotropin (TSH) Precipitable Percentage (Macro-TSH) in Patients with a History of Thyroid Cancer. Endocrinol Metab (Seoul) 2017; 32:460-465. [PMID: 29271618 PMCID: PMC5744732 DOI: 10.3803/enm.2017.32.4.460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/22/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Owing to its large molecular size, polyethylene glycol (PEG)-precipitable thyrotropin (TSH) can accumulate in the circulation, elevating TSH levels. PEG-precipitable TSH can be used to detect macro-TSH (mTSH) in serum. Our aim was to evaluate the prevalence of mTSH in patients who had undergone thyroidectomy for thyroid cancer. METHODS Seventy-three thyroid cancer patients and 24 control subjects on levothyroxine (LT4) TSH-suppressive or replacement therapy were evaluated. Screening for mTSH was performed by adding PEG to serum in order to precipitate γ-globulin. A percentage of PEG-precipitable TSH ≥80% was considered suggestive of mTSH. RESULTS No correlation between free-T4 (fT4) and TSH levels was found. PEG-precipitable TSH was 39.3%±1.9% in thyroid cancer patients and 44.1%±3.9% in controls. Macro-TSH was deemed to be present in one thyroid cancer patient and in two control subjects. Only in the thyroid cancer group was PEG-precipitable TSH found to be negatively correlated with fT4 concentration. No correlation was found between PEG-precipitable TSH and other clinical conditions in any patients. CONCLUSION The presence of mTSH seems to be a rare phenomenon in thyroid cancer. In some patients with low PEG-precipitable TSH, a reduction in LT4 dosage could be suggested. LT4 dosage adjusted to body weight is the main factor in maintaining TSH in a semi-suppressed or normal range. Evaluation of mTSH could be necessary in patients in whom a balance is required between adequate TSH suppression and the avoidance of unnecessary exogenous hyperthyroxinemia.
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Affiliation(s)
- Massimo Giusti
- Department of Internal Medicine, University of Genoa, Genoa, Italy.
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | - Lucia Conte
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | | | - Stefano Gay
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | - Paola Marroni
- Laboratory Analysis Unit, San Martino University Hospital, Genoa, Italy
| | - Miranda Mittica
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Michele Mussap
- Laboratory Analysis Unit, San Martino University Hospital, Genoa, Italy
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89
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Blackburn BE, Ganz PA, Rowe K, Snyder J, Wan Y, Deshmukh V, Newman M, Fraser A, Smith K, Herget K, Kim J, Kirchhoff AC, Porucznik C, Hanson H, Monroe M, Hashibe M. Aging-Related Disease Risks among Young Thyroid Cancer Survivors. Cancer Epidemiol Biomarkers Prev 2017; 26:1695-1704. [PMID: 29167277 DOI: 10.1158/1055-9965.epi-17-0623] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/29/2017] [Accepted: 09/22/2017] [Indexed: 01/13/2023] Open
Abstract
Background: Thyroid cancer is the most rapidly increasing cancer in the United States, affects a young population, has high survival, and is one of the most common cancers in people under age 40. The aim of this study was to examine the risks of aging-related diseases in a statewide sample of thyroid cancer survivors who were diagnosed <40 years compared with those diagnosed ≥40 and a cancer-free sample.Methods: Thyroid cancer survivors diagnosed 1997 to 2012 were matched to up to 5 cancer-free individuals on birth year, sex, birth state, using the statewide Utah Population Database. Medical records were used to identify disease diagnoses stratified over three time periods: 1 to 5, >5 to 10, and 10+ years after cancer diagnosis. Cox proportional hazards models were used to estimate hazard ratios with adjustment on matching factors, race, body mass index, and Charlson Comorbidity Index.Results: There were 3,706 thyroid cancer survivors and 15,587 matched cancer-free individuals (1,365 cases diagnosed <40 years old). Both age groups had increased risks for multiple circulatory health conditions 1 to 5 years after cancer diagnosis compared with cancer-free individuals. Survivors <40 had a higher risk of hypertension, cardiomyopathy, and nutritional deficiencies.Conclusions: Increased risks for diseases associated with aging were observed for both age groups, with younger thyroid cancer survivors having higher risks for select diseases.Impact: As thyroid cancer survivors in this study were found to have increased risks for aging-related diseases, future studies are needed to assess what can be done to reduce the increased risks of these long-term health effects. Cancer Epidemiol Biomarkers Prev; 26(12); 1695-704. ©2017 AACR.
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Affiliation(s)
- Brenna E Blackburn
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Ganz
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Kerry Rowe
- Intermountain Healthcare, Salt Lake City, Utah
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, Utah
| | - Yuan Wan
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | | | - Michael Newman
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Alison Fraser
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ken Smith
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Kimberly Herget
- Utah Cancer Registry, University of Utah, Salt Lake City, Utah
| | - Jaewhan Kim
- Health Promotion and Education, Department of Health, Kinesiology, and Recreation, University of Utah College of Health, Salt Lake City, Utah
| | - Anne C Kirchhoff
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christina Porucznik
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Heidi Hanson
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Marcus Monroe
- Huntsman Cancer Institute, Salt Lake City, Utah
- Division of Otolaryngology, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Mia Hashibe
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah.
- Huntsman Cancer Institute, Salt Lake City, Utah
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90
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Liu X, Zhou Y, Liang N, Hong Y, Dionigi G, Sun H. The effect of long-term thyroid-stimulating hormone suppressive therapy on the gonadal steroid hormones of patients with thyroid carcinoma after surgery. Gland Surg 2017; 6:443-452. [PMID: 29142833 DOI: 10.21037/gs.2017.09.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background To analyze the effect of long-term thyroid-stimulating hormone (TSH) suppressive therapy on the gonadal hormones and related symptoms in patients after surgery. Methods From 2008 to 2011, totally 238 patients were recruited, who underwent thyroid surgery and subsequent TSH suppression treatment in Department of thyroid Surgery, China-Japan Union hospital, Jilin University. Then their postoperative follow-up data (3-8 years) were collected, including operational method, pathological diagnosis, whether processed radioiodine therapy and the period/dose of TSH suppression treatment. In addition, the menstrual cycle, menstruation quantity, whether accompanied with dysmenorrheal and menstrual disorder or not, date of last menstrual period, ages of menopause and so on were also collected. Results (I) Neither the level nor the duration of TSH treatment had any function on estradiol (E2) and testosterone (T) in male patients; (II) in the subgroup of patients with TSH treatment for 3-5 years, patients who took high dose of TSH (TSH ≥0.5 U/L) obtained the lower T level compared with the group of medium dose (1.08±0.34 vs. 1.36±0.46 nmol/L, P=0.001); (III) in the medium dose (0.1 IU/L ≤ TSH <0.5 IU/L) of TSH treatment, patients in luteal phase showed significant difference between two separate durations as the E2 level was 196.0 pmol/L in 3-5 years group vs. 442.5 pmol/L in 6-8 years group, P=0.018; (IV) the level of follicle-stimulating hormone (FSH) did not show any change in terms of the dose and the duration of TSH treatment; (V) the menstrual volume, dysmenorrhea condition, menstrual cycle and menopause related indicators did not show any difference in terms of doses and duration of TSH treatment (P=0.701, 0.412 and 0.507 respectively). Conclusions The long term of TSH repressive therapy after surgery did not affect T and E2 level in male patients. As for female patients, the impact was mainly reflected in the T and E2 levels especially in female sexual maturity but not FSH level. In addition, TSH treatment did not play any role on menstruation or menopause.
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Affiliation(s)
- Xiaoli Liu
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun 130031, China
| | - Ying Zhou
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun 130031, China
| | - Nan Liang
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun 130031, China
| | - Yang Hong
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun 130031, China
| | - Gianlorenzo Dionigi
- Division for Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital G. Martino, University of Messina, Messina, Italy
| | - Hui Sun
- Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun 130031, China
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91
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Kim HI, Kim TH, Kim H, Kim YN, Jang HW, Kim JH, Hur KY, Chung JH, Kim SW. Delayed TSH recovery after dose adjustment during TSH-suppressive levothyroxine therapy of thyroid cancer. Clin Endocrinol (Oxf) 2017; 87:286-291. [PMID: 28375573 DOI: 10.1111/cen.13344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 03/09/2017] [Accepted: 03/30/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Delayed thyroid-stimulating hormone (TSH) recovery during treatment of Graves' disease is caused by long-term excessive thyroid hormone, which results in downregulation of pituitary thyrotrophs. However, it is unknown whether delayed TSH recovery exists after levothyroxine (LT4) dose reduction in patients with differentiated thyroid cancer (DTC) after long-term TSH suppression. METHODS We retrospectively reviewed 97 DTC patients with LT4 dose reduction after long-term TSH suppression. TSH levels at baseline (point 1), 6 months (point 2) and 12-18 months (point 3) after LT4 dose reduction were compared. A delayed TSH recovery group whose TSH levels changed to upper target TSH category (2015 revised ATA guidelines) from point 2 to point 3 was identified, and risk factors were analysed. RESULTS The median TSH level at point 3 was significantly higher than that of point 2 (0.17 vs 0.09 mIU/L; P<.001). The delayed TSH recovery group (44.3%) showed increased body weight (60.84 vs 62.73 kg; P=.01), while normal response group did not. Greater reduction (%) in the LT4 dose per weight [HR 1.10, 95% CI (1.00-1.22), P=.04] and higher BMI before thyroid surgery [1.19, 1.03-1.38, P=.01] predicted the occurrence of delayed TSH recovery, while higher dose of LT4 per weight after reduction showed preventive effect [HR 0.01, 95% CI (0.00-0.54); P=.02]. CONCLUSIONS Delayed TSH recovery was common during LT4 dose reduction after long-term TSH suppression for DTC management. Six months may not be enough for TSH recovery and to evaluate thyroid hormone status by serum TSH.
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Affiliation(s)
- Hye In Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hosu Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Nam Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Department of Medical Education, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu Yeon Hur
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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92
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Haymart MR, Esfandiari NH, Stang MT, Sosa JA. Controversies in the Management of Low-Risk Differentiated Thyroid Cancer. Endocr Rev 2017; 38. [PMID: 28633444 PMCID: PMC5546880 DOI: 10.1210/er.2017-00067] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Controversy exists over optimal management of low-risk differentiated thyroid cancer. This controversy occurs in all aspects of management, including surgery, use of radioactive iodine for remnant ablation, thyroid hormone supplementation, and long-term surveillance. Limited and conflicting data, treatment paradigm shifts, and differences in physician perceptions contribute to the controversy. This lack of physician consensus results in wide variation in patient care, with some patients at risk for over- or undertreatment. To reduce patient harm and unnecessary worry, there is a need to design and implement studies to address current knowledge gaps.
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Affiliation(s)
- Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Nazanene H Esfandiari
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109
| | - Michael T Stang
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
| | - Julia Ann Sosa
- Division of Endocrine Surgery, Department of Surgery, Duke University, Durham, North Carolina 27710
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93
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Freudenthal B, Williams G. Thyroid Stimulating Hormone Suppression in the Long-term Follow-up of Differentiated Thyroid Cancer. Clin Oncol (R Coll Radiol) 2017; 29:325-328. [DOI: 10.1016/j.clon.2016.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/08/2023]
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94
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Metástasis a distancia en cáncer diferenciado de tiroides: diagnóstico y tratamiento. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.raem.2017.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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95
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Park S, Jeon MJ, Song E, Oh HS, Kim M, Kwon H, Kim TY, Hong SJ, Shong YK, Kim WB, Sung TY, Kim WG. Clinical Features of Early and Late Postoperative Hypothyroidism After Lobectomy. J Clin Endocrinol Metab 2017; 102:1317-1324. [PMID: 28324106 DOI: 10.1210/jc.2016-3597] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/06/2017] [Indexed: 12/26/2022]
Abstract
CONTEXT Lobectomy is preferred in thyroid cancer to decrease surgical complications and avoid lifelong thyroid-hormone replacement. However, postoperative hypothyroidism, requiring thyroid-hormone replacement, may occur. OBJECTIVE We aimed to identify the incidence and risk factors of postoperative hypothyroidism to develop a surveillance strategy after lobectomy for papillary thyroid microcarcinoma (PTMC). METHODS This historical cohort study involved 335 patients with PTMC treated by lobectomy. Postoperative thyroid functions were measured regularly, and patients were prescribed levothyroxine according to specific criteria. Patients not satisfying hormone-replacement criteria were closely followed up. RESULTS Postoperative hypothyroidism occurred in 215 patients (64.2%) including 5 (1.5%) with overt hypothyroidism and 210 (62.7%) with subclinical hypothyroidism. Forty patients (11.9%) were required thyroid hormone replacement. One hundred nineteen patients (33.5%) experienced temporary hypothyroidism and spontaneously recovered to euthyroid state. High preoperative thyroid-stimulating hormone (TSH) was the most important factor predicting postoperative hypothyroidism and failure of recover from hypothyroidism (odds ratio [OR], 2.82 and 1.77; 95% confidence interval [CI], 2.07 to 3.95 and 1.22 to 2.63; P < 0.001 and 0.002, respectively). Of the 215 patients eventually developing postoperative hypothyroidism, 70 (32.6%) developed hypothyroidism after the first postoperative year. Postoperative 1-year TSH levels were able to differentiate patients developing late hypothyroidism or euthyroidism (OR, 2.29; 95% CI, 1.68 to 3.26; P < 0.001). CONCLUSIONS Preoperative and postoperative TSH levels might be predictive for patients who develop postlobectomy hypothyroidism and identify those requiring long-term surveillance for hypothyroidism. Additionally, mild postoperative hypothyroidism cases should be followed up without immediate levothyroxine replacement with the expectation of spontaneous recovery.
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Affiliation(s)
| | | | - Eyun Song
- Departments of Internal Medicine and
| | | | - Mijin Kim
- Departments of Internal Medicine and
| | | | | | - Suck Joon Hong
- Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
| | | | | | - Tae-Yon Sung
- Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea
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96
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Cappelli C, Pirola I, Gandossi E, Casella C, Lombardi D, Agosti B, Marini F, Delbarba A, Castellano M. TSH Variability of Patients Affected by Differentiated Thyroid Cancer Treated with Levothyroxine Liquid Solution or Tablet Form. Int J Endocrinol 2017; 2017:7053959. [PMID: 28572820 PMCID: PMC5441121 DOI: 10.1155/2017/7053959] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/13/2017] [Accepted: 03/22/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recent guidelines from the American Thyroid Association (ATA) indicate that, in many patients affected by differentiated thyroid cancer (DTC), the serum TSH should be maintained between 0.1 and 0.5 mU/L. The purpose of this study was to evaluate the TSH variability of patients affected by DTC treated with liquid L-T4 formulation or in tablet form. PATIENTS AND METHODS Patients were eligible if (a) they were submitted to a total thyroidectomy and 131I remnant ablation for DTC in our institution and (b) they were classified low-risk patients according to ATA guidelines 2009. Patients were randomized (1 : 1) to receive treatment of hypothyroidism with liquid L-T4 or tablet form. The first check-up evaluation was made from 8 to 12 months after 131I remnant ablation. TSH values were established again after further 12 months. RESULTS A significant increase in TSH values (median) was observed in patients taking tablets [TSH (min-max): 0.28 (0.1-0.45) versus 0.34 (0.01-0.78) mIU/L, p = 0.041] as compared to those taking liquid formulation [TSH (min-max): 0.28 (0.1-0.47) versus 0.30 (0.1-0.55) mIU/L, p = 0.345]. CONCLUSIONS The use of L-T4 liquid formulation, as compared to that of tablets, resulted in a significantly higher number of DTC patients maintaining TSH values in range for the ATA risk score, reducing TSH variability over the time.
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Affiliation(s)
- Carlo Cappelli
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
- *Carlo Cappelli:
| | - Ilenia Pirola
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Elena Gandossi
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, 3rd Division of General Surgery, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Davide Lombardi
- Department of Otorhinolaryngology, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Barbara Agosti
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Fiorella Marini
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Andrea Delbarba
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
| | - Maurizio Castellano
- Department of Medical and Surgical Sciences, Endocrine and Metabolic Unit, Clinica Medica, 2nd Medicina, Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy
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97
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Biondi B, Bartalena L, Chiovato L, Lenzi A, Mariotti S, Pacini F, Pontecorvi A, Vitti P, Trimarchi F. Recommendations for treatment of hypothyroidism with levothyroxine and levotriiodothyronine: a 2016 position statement of the Italian Society of Endocrinology and the Italian Thyroid Association. J Endocrinol Invest 2016; 39:1465-1474. [PMID: 27473077 DOI: 10.1007/s40618-016-0511-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/06/2016] [Indexed: 02/08/2023]
Abstract
Levothyroxine (L-T4) is recommended as lifelong replacement therapy for hypothyroidism. Recent clinical and experimental data support the addition of levotriiodothyronine (L-T3) treatment in some selected hypothyroid patients when their symptoms persist and their quality of life remains impaired despite adequate L-T4 monotherapy. An increase in L-T3 prescriptions has been recently observed in Italy due to availability of different L-T3 formulations, making it possible to clinicians to prescribe L-T3 alone or in combination with L-T4. The aim of the present position statement was to define the correct clinical indications, schedule, duration of treatment and contraindications of combined treatment with L-T4 and L-T3 in hypothyroid patients in an attempt to guide clinicians and to avoid potential adverse effects of overtreatment.
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Affiliation(s)
- B Biondi
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via S. Pansini 5, 80131, Naples, Italy.
| | - L Bartalena
- Department of Clinical and Experimental Medicine, ASST dei Sette Laghi, Ospedale di Circolo, University of Insubria, Varese, Italy
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Fondazione Salvatore Maugeri and University of Pavia, Pavia, Italy
| | - A Lenzi
- Department of Experimental Medicine, Medical Pathophysiology, Food and Science and Endocrinology Section, Sapienza University of Rome, Rome, Italy
| | - S Mariotti
- Endocrinology Unit, Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - F Pacini
- Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - A Pontecorvi
- Unità di Endocrinologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - F Trimarchi
- Accademia Peloritana dei Pericolanti, Università di Messina, Messina, Italy
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98
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Hosseini SM, Bakhtyari EK, Heshmat-Ghahdarijani K, Khalili N. Evaluation of endothelial function in exogenous subclinical hyperthyroidism and the effect of treatment. Adv Biomed Res 2016; 5:173. [PMID: 28028513 PMCID: PMC5157004 DOI: 10.4103/2277-9175.194800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 02/20/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Subclinical hyperthyroidism (SHy) is a widespread condition in which cardiovascular manifestations are frequently occur, but there is still a debate about the vascular responsiveness in it. Measuring flow-mediated dilation (FMD) and intimae-media thickness (IMT) are used to evaluate endothelial function in these patients. MATERIALS AND METHODS Twenty-five patients with a diagnosis of exogenous SHy and 25 full matched healthy subjects were enrolled. At first FMD of brachial artery and IMT of common carotid artery were obtained from all the participants. In the second phase, in the second phase of study, the dosage of levothyroxine was reduced at least 25% of prior dosage, and this was continued until thyroid stimulating hormone became normal range. Measuring FMD and IMT was repeated after this intervention in the case group. RESULTS The mean age of case and control groups were 38.48 ± 12.05 and 36.72 ± 11.15 years, respectively. The mean of FMD in healthy people was dramatically higher than the subclinical hyperthyroid patients (P < 0.001) but no statistically significant difference was found for IMT (P = 0.459). After intervention in the case group, FMD was meaningfully increased (P < 0.001) but IMT of common carotid artery was not considerably changed (P = 0.491). CONCLUSIONS This study demonstrated that FMD decreased in exogenous subclinical hyperthyroid patients which could be partially restored by treatment. These findings suggest that treatment of subclinical hyperthyroid state could improve endothelial dysfunction and at the end decreased the cardiovascular complications.
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Affiliation(s)
- Sayed Mohammad Hosseini
- Department of Internal Medicine, Isfahan Endocrine and Metabolism Research Center, Isfahan, Iran
| | | | | | - Noushin Khalili
- Department of Internal Medicine, Isfahan Endocrine and Metabolism Research Center, Isfahan, Iran
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99
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Lorusso L, Pieruzzi L, Biagini A, Sabini E, Valerio L, Giani C, Passannanti P, Pontillo-Contillo B, Battaglia V, Mazzeo S, Molinaro E, Elisei R. Lenvatinib and other tyrosine kinase inhibitors for the treatment of radioiodine refractory, advanced, and progressive thyroid cancer. Onco Targets Ther 2016; 9:6467-6477. [PMID: 27799794 PMCID: PMC5079697 DOI: 10.2147/ott.s84625] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Lenvatinib is a small oral molecule able to inhibit three of the extracellular and intracellular molecules involved in the modulation of angiogenesis and lymphangiogenesis: vascular endothelial growth factor receptor 1–3, fibroblast growth factor receptor 1–4, and platelet-derived growth factor receptor alpha. Since it is also able to inhibit the REarranged during Transfection oncogene and the protooncogene c-KIT, this drug can also be used to control tumor cell proliferation. The maximum tolerated dose, as demonstrated in Phase I studies, is 25 mg daily. The drug is rapidly absorbed with maximum concentrations achieved within 3 and 5 hours after administration in fasting and nonfasting treated patients, respectively. The most common adverse events, reported in Phase I study and confirmed in the subsequent Phase II and III studies, are hypertension, proteinuria, and gastrointestinal symptoms such as nausea, diarrhea, and stomatitis. In Phase I studies, efficacy of lenvatinib in solid tumors was demonstrated, and these encouraging results have led to the development of a Phase II study using lenvatinib in advance radioiodine-refractory differentiated thyroid cancer (DTCs) patients. Since an overall response rate of 50% was reported, this study also confirmed the efficacy of lenvatinib in DTCs patients with an acceptable toxicity profile. Recently, a Phase III study in patients with DTCs (SELECT study) demonstrated the lenvatinib efficacy in prolonging progression-free survival with respect to the placebo (18.3 vs 3.6 months; P<0.001). Although there was no statistically significant difference in the overall survival of the entire group, this result was observed when the analysis was restricted to both the follicular histotype and the group of senior patients (>65 years). The study confirmed that the most common side effects of this drug are hypertension, diarrhea, decreased appetite, weight loss, nausea, and proteinuria. In this review, we report the results of the main studies on lenvatinib efficacy in patients with advanced and progressive thyroid cancer, mainly in DTCs but also in medullary and anaplastic thyroid cancer. We also compared the efficacy of lenvatinib with that of other tyrosine kinase inhibitors, mainly sorafenib, already tested in the same type of patient population.
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Affiliation(s)
- Loredana Lorusso
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | - Letizia Pieruzzi
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | - Agnese Biagini
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | - Elena Sabini
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | - Laura Valerio
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | - Carlotta Giani
- Endocrine Unit, Department of Clinical and Experimental Medicine
| | | | | | - Valentina Battaglia
- Division of Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy
| | - Salvatore Mazzeo
- Division of Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy
| | | | - Rossella Elisei
- Endocrine Unit, Department of Clinical and Experimental Medicine
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100
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Haugen BR. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: What is new and what has changed? Cancer 2016; 123:372-381. [PMID: 27741354 DOI: 10.1002/cncr.30360] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/30/2016] [Accepted: 09/01/2016] [Indexed: 01/13/2023]
Abstract
Thyroid nodules are very common, and thyroid cancer is currently the fifth leading cancer diagnosis in women. The American Thyroid Association has led the development and revision of guidelines for the management of patients with thyroid nodules and differentiated thyroid cancer (DTC). The most current revision was published in the January 2016 issue of the journal Thyroid. The current guidelines have 101 recommendations, with 8 figures and 17 tables that are hopefully helpful to those treating patients with thyroid nodules and cancer. The primary goals of the American Thyroid Association Guidelines Task Force were to use the current evidence to guide recommendations and yet be as helpful and practical as possible within the scope and strength of the evidence. The current review focuses on new and significantly revised recommendations that may very well change clinical practice. The author notes 3 new basic principles that have emerged in this guidelines revision: 1) the management of thyroid nodules, including the decision to perform a fine-needle aspiration biopsy as well as follow-up decision making, will be heavily influenced by the newly developed sonographic risk pattern; 2) the long-term management of DTC along with thyroid-stimulating hormone target goals will be heavily influenced by the 4 categories of "response to therapy"; and 3) the management of patients with radioactive iodine-refractory DTC will be divided into 4 basic decision-making groups: patients who should undergo monitoring, patients who should undergo directed therapies, patients who should undergo systemic therapies, and patients who should be offered entry into clinical trials. Cancer 2017;123:372-381. © 2016 American Cancer Society.
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Affiliation(s)
- Bryan R Haugen
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado Cancer Center, University of Colorado School of Medicine, Aurora, Colorado
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