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Massimino M, Podda M, Gandola L, Pignoli E, Seregni E, Morosi C, Spreafico F, Ferrari A, Pecori E, Terenziani M. Long-term results of suppressing thyroid-stimulating hormone during radiotherapy to prevent primary hypothyroidism in medulloblastoma/PNET and Hodgkin lymphoma: a prospective cohort study. Front Med 2020; 15:101-107. [PMID: 32794013 DOI: 10.1007/s11684-020-0752-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/14/2020] [Indexed: 10/23/2022]
Abstract
Primary hypothyroidism commonly occurs after radiotherapy (RT), and coincides with increased circulating thyroid-stimulating hormone (TSH) levels.We tested therefore the protective effect of suppressing TSH with L-thyroxine during RT for medulloblastoma/PNET and Hodgkin lymphoma (HL) in a prospective cohort study. From1998 to 2001, a total of 37 euthyroid children with medulloblastoma/PNET plus 14 with HL, scheduled for craniospinal irradiation and mediastinum/neck radiotherapy, respectively, underwent thyroid ultrasound and free triiodothyronine (FT3), free thyroxine (FT4), and TSH evaluation at the beginning and end of craniospinal iiradiation. From 14 days before and up to the end of radiotherapy, patients were administered L-thyroxine checking every 3 days TSH to ensure a value < 0.3 μIU/mL. During follow-up, blood tests and ultrasound were repeated; primary hypothyroidism was considered an increased TSH level greater than normal range. Twenty-two/37 patients with medulloblastoma/PNET and all the 14 patients with HL were alive after a median 231 months from radiotherapy with 7/22 and 8/14 having correctly reached TSH levels < 0.3 μIU/mL and well matched for other variables. Twenty years on, hypothyroidism-free survival rates differed significantly, being 60% ± 15% and 15.6% ± 8.2% in TSH-suppressed vs. not-TSH suppressed patients, respectively (P = 0.001). These findings suggest that hypothyroidism could be durably prevented in two populations at risk of late RT sequelae, but it should be confirmed in a larger cohort.
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Affiliation(s)
- Maura Massimino
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy.
| | - Marta Podda
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Ettore Seregni
- Department of Nuclear Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Carlo Morosi
- Department of Radiology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Filippo Spreafico
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Andrea Ferrari
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Emilia Pecori
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
| | - Monica Terenziani
- Pediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, 20146, Italy
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Barnum JL, Petryk A, Zhang L, DeFor TE, Baker KS, Steinberger J, Nathan B, Wagner JE, MacMillan ML. Endocrinopathies, Bone Health, and Insulin Resistance in Patients with Fanconi Anemia after Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2016; 22:1487-1492. [PMID: 27180116 DOI: 10.1016/j.bbmt.2016.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/03/2016] [Indexed: 01/25/2023]
Abstract
A number of endocrinopathies have been described after hematopoietic cell transplantation (HCT), but data are limited in patients with Fanconi anemia (FA). We report several endocrine-based disorders in a cohort of 44 patients with FA after HCT compared with both 74 patients who received HCT for hematologic malignancies and with 275 healthy controls. Endocrinopathies assessed included hypothyroidism, hypogonadism, short stature, dyslipidemia, insulin resistance, abnormalities in body composition, and bone health. Most (86%) patients with FA had at least 1 endocrinopathy, with 11% having 3 or more. Hypothyroidism was seen in 57%, hypogonadism in 27%, short stature in 50%, and reduced total body and lumbar spine bone mineral density (BMD) (height adjusted Z-score < -1) in 57% and 21%, respectively. Vitamin D deficiency was seen in 71%. Short stature was associated with younger age at HCT and gonadal failure was associated with older age at HCT. Insulin resistance was associated with increased percent fat mass and increased android/gynoid ratio by dual energy X-ray absorptiometry. Hypothyroidism, short stature, and reduced total body BMD were more prevalent in patients with FA compared with patients with hematologic malignancies. We recommend an assessment before transplantation and close follow-up afterwards to ensure proper clinical management. Future studies should continue to explore the impact of HCT on endocrinopathies in FA patients.
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Affiliation(s)
- Jessie L Barnum
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Anna Petryk
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - Lei Zhang
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Biostatistics and Informatics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Brandon Nathan
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Division of Endocrinology, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota.
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Lauro C, Macy ME, Zeitler P, Backus J, Mettler P, Foreman N, Liu AK. The relationship between thyroid dose and diagnosis of primary hypothyroidism in pediatric brain tumor patients receiving craniospinal irradiation. J Pediatr Endocrinol Metab 2014; 27:299-303. [PMID: 24057590 PMCID: PMC4172576 DOI: 10.1515/jpem-2013-0063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 08/20/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim of this work is to determine if a relationship exists between thyroid dose and incidence of primary hypothyroidism (PH) in children undergoing craniospinal irradiation (CSI). METHODS A total of 22 patients received CSI with evaluable thyroid dose information. All patients received concurrent chemotherapy and 21 patients (95%) received adjuvant chemotherapy. Median follow-up was 42.9 months. RESULTS The incidence of PH in our cohort was 59% at a median time after radiotherapy of 3.5 years (range: 8 months to 7.5 years). Mean thyroid dose appeared to best predict for PH, with a median of 2080 cGy for patients with PH versus 1736 cGy for children without PH (p=0.057). There was no association between the rate of PH and sex, age, CSI dose, minimum thyroid dose and maximum thyroid dose. CONCLUSIONS A relationship may exist between the mean thyroid dose and incidence of PH in patients undergoing CSI. Thus, new strategies to protect the thyroid gland may be warranted.
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Affiliation(s)
- Christine Lauro
- Corresponding author: Christine Lauro, MD, University of Colorado-Radiation Oncology, Mail Stop F706 1665 Aurora Court, Suite 1032, Aurora, CO 80045, USA, Phone: +1-720-848-0106, Fax: +1-720-848-0222,
| | | | - Philip Zeitler
- Children's Hospital Colorado-Pediatric Endocrinology, CO, USA
| | - Jennifer Backus
- University of Colorado Denver-Radiation Oncology, Aurora, CO, USA
| | - Pamela Mettler
- University of Colorado Denver-Biostatistics and Informatics, Aurora, CO, USA
| | | | - Arthur K. Liu
- University of Colorado Denver-Radiation Oncology, Aurora, CO, USA
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Mascarin M, Giugliano FM, Coassin E, Drigo A, Chiovati P, Dassie A, Franchin G, Minatel E, Trovò MG. Helical tomotherapy in children and adolescents: dosimetric comparisons, opportunities and issues. Cancers (Basel) 2011; 3:3972-90. [PMID: 24213120 PMCID: PMC3763405 DOI: 10.3390/cancers3043972] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 10/07/2011] [Accepted: 10/17/2011] [Indexed: 01/26/2023] Open
Abstract
Helical Tomotherapy (HT) is a highly conformal image-guided radiation technique, introduced into clinical routine in 2006 at the Centro di Riferimento Oncologico Aviano (Italy). With this new technology, intensity-modulated radiotherapy (IMRT) is delivered using a helicoidal method. Here we present our dosimetric experiences using HT in 100 children, adolescents and young adults treated from May 2006 to February 2011. The median age of the patients was 13 years (range 1-24). The most common treated site was the central nervous system (50; of these, 24 were craniospinal irradiations), followed by thorax (22), head and neck (10), abdomen and pelvis (11), and limbs (7). The use of HT was calculated in accordance to the target dose conformation, the target size and shape, the dose to critical organs adjacent to the target, simultaneous treatment of multiple targets, and re-irradiation. HT has demonstrated to improve target volume dose homogeneity and the sparing of critical structures, when compared to 3D Linac-based radiotherapy (RT). In standard cases this technique represented a comparable alternative to IMRT delivered with conventional linear accelerator. In certain cases (e.g., craniospinal and pleural treatments) only HT generated adequate treatment plans with good target volume coverage. However, the gain in target conformality should be balanced with the spread of low-doses to distant areas. This remains an open issue for the potential risk of secondary malignancies (SMNs) and longer follow-up is mandatory.
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Affiliation(s)
- Maurizio Mascarin
- Pediatric Radiotherapy Unit, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (F.M.G.); (E.C.)
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +39-0434-659-523; Fax: +39-0434-659-524
| | - Francesca Maria Giugliano
- Pediatric Radiotherapy Unit, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (F.M.G.); (E.C.)
- Seconda Università di Napoli, Napoli 80138, Italy
| | - Elisa Coassin
- Pediatric Radiotherapy Unit, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (F.M.G.); (E.C.)
| | - Annalisa Drigo
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
- Department of Medical Physics, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy
| | - Paola Chiovati
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
- Department of Medical Physics, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy
| | - Andrea Dassie
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
- Department of Medical Physics, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy
| | - Giovanni Franchin
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
| | - Emilio Minatel
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
| | - Mauro Gaetano Trovò
- Department of Radiation Therapy, Centro di Riferimento Oncologico- National Cancer Institute/Via Franco Gallini, 2 33081 Aviano (PN) Italy; E-Mails: (A.D.); (P.C.); (A.D.); (G.F.); (E.M.); (M.G.T.)
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Dvorak CC, Gracia CR, Sanders JE, Cheng EY, Baker KS, Pulsipher MA, Petryk A. NCI, NHLBI/PBMTC first international conference on late effects after pediatric hematopoietic cell transplantation: endocrine challenges-thyroid dysfunction, growth impairment, bone health, & reproductive risks. Biol Blood Marrow Transplant 2011; 17:1725-38. [PMID: 22005649 DOI: 10.1016/j.bbmt.2011.10.006] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 10/10/2011] [Indexed: 12/12/2022]
Abstract
The endocrine system is highly susceptible to damage by high-dose chemotherapy and/or irradiation before hematopoietic cell transplantation (HCT) during childhood. The specific endocrine organs most affected by HCT include the thyroid gland, the pituitary, and the gonads. In addition, hormones that support development and stability of the skeletal system are also affected. Insufficiency of thyroid hormone is 1 of the most common late sequelae of HCT, and occurs more often in young children. Deficiency in the pituitary's production of growth hormone is a problem of unique concern to the pediatric population. The reproductive risks of HCT depend on the patient's gender and pubertal status at the time of HCT. Pubertal or gonadal failure frequently occurs, especially in females. Infertility risks for both genders remain high, whereas methods of fertility preservation are limited in all but postpubertal males. Bone health post-HCT can be compromised by low bone mineral density as well as avascular necrosis, but the data on both problems in the pediatric HCT population are limited. In this paper, the current state of knowledge, gaps in that knowledge, and recommendations for future research are addressed in detail for each of these systems.
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Affiliation(s)
- Christopher C Dvorak
- Division of Pediatric Blood & Marrow Transplant, University of California San Francisco, San Francisco, California, USA
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