Organ Dose Estimates for Hyperthyroid Patients Treated with (131)I: An Update of the Thyrotoxicosis Follow-Up Study

Enhanced Internal Dosimetry for Alimentary Tract Organs in Nuclear Medicine based on the ICRP Mesh-Type Reference Phantoms

This study introduces a refined approach for more accurately estimating radiation doses to alimentary tract organs in nuclear medicine, by utilizing the ICRP pediatric and adult mesh-type reference computational phantoms (MRCPs) that improved the anatomical representation of these organs. Our initial step involved compiling a comprehensive dataset of electron Specific Absorbed Fractions (SAFs) for all source-target pairs of alimentary tract organs in both adult and pediatric phantoms, calculating SAFs for all cases in the present study only except those computed in the previous study for certain pediatric phantom cases. Subsequently, we determined S values for 1,252 radionuclides, facilitating dosimetry applications. The consistency of target and source masses for alimentary tract organs in the MRCPs with the reference values in ICRP Publication 89 led to noticeable differences in SAF, S values, and consequently, absorbed dose coefficients when compared to the stylized models in ICRP Publication 100. Notably, the S value ratios (MRCP/stylized) for selected radionuclides-11C, 18F, 68Ga, and 131I-ranged from 0.41 to 7.60. Particularly for therapeutic 131I-iodide in thyroid cancer, the use of MRCPs resulted in up to 1.49 times higher absorbed dose coefficients for the colon than those derived from stylized models, while the stomach dose coefficients decreased by a factor of 0.72. The application of our findings promises enhanced, more realistic dosimetry for alimentary tract organs, especially beneficial for radiopharmaceuticals likely to accumulate within these organs.

Links between Breast and Thyroid Cancer: Hormones, Genetic Susceptibility and Medical Interventions

Breast and thyroid glands are two common sites of female malignancies. Since the late 19th century, physicians have found that the cancers in either thyroid or mammary gland might increase the risk of second primary cancers in the other site. From then on, many observational clinical studies have confirmed the hypothesis and more than one theory has been developed to explain the phenomenon. Since the two glands both have secretory functions and are regulated by the hypothalamic-pituitary axis, they may share some common oncogenic molecular pathways. However, other risks factors, including medical interventions and hormones, are also observed to play a role. This article aims to provide a comprehensive review of the associations between the two cancers. The putative mechanisms, such as hormone alteration, autoimmune attack, genetic predisposition and other life-related factors are reviewed and discussed. Medical interventions, such as chemotherapy and radiotherapy, can also increase the risk of second primary cancers. This review will provide novel insights into the research designs, clinical managements and treatments of thyroid and breast cancer patients.

Does Radioactive Iodine Therapy for Hyperthyroidism Cause Cancer?

Radioactive iodine has been considered a safe and effective therapeutic option for hyperthyroidism secondary to Graves disease and autonomously functioning thyroid nodules since the mid-20th century. The question of whether I-131 at the doses used for hyperthyroidism might increase the risk of cancer has been investigated in a number of observational cohort studies over the years, with the preponderance of evidence being reassuring as to its safety. In particular, the 1998 Cooperative Thyrotoxicosis Therapy Follow-up Study (CTTFUS) has been widely cited as compelling evidence that I-131 is safe in hyperthyroidism therapy with respect to carcinogenesis. However, in 2019, a study by Kitahara and colleagues re-analyzed the CTTFUS cohort, extending the follow-up time and applying a novel dosimetric model for estimating tissue absorbed doses of radiation. This new analysis concluded that radioactive iodine was associated with an increased risk for mortality from overall cancer, breast cancer, and non-breast solid cancers. Reaction to this study was vociferous and particularly negative in the nuclear medicine literature. This mini-review was inspired by the 2019 CTTFUS controversy, and it is intended to provide the necessary context for clinicians to provide nuanced advice to their patients on the subject. To that end, the pre-2019 literature is surveyed, the 2019 CTTFUS study and a 2020 follow-up are discussed, and lessons from the literature and critical commentaries are considered.

Effect of 131I with and without artificial liver support system in patients with Graves' disease and severe liver dysfunction: A retrospective study

OBJECTIVE

Treatment decision-making in Graves' disease (GD) with severe liver dysfunction (LD) is a clinical challenge. This research was carried out to evaluate the effect of radioiodine (¹³¹I) with or without an artificial liver support system (ALSS) in GD patients with severe LD.

METHODS

In total, 45 patients diagnosed with GD and severe LD were enrolled and allocated to two groups: patients treated with ¹³¹I alone (n=30) (Group A)and patients by a combination of ¹³¹I and ALSS (n=15)(Group B). Liver function, thyroid hormone concentrations, therapeutic efficacy, and the cost of treatment were compared between the two groups.

RESULTS

Thyroid hormone concentrations were lower 2 weeks after ¹³¹I treatment, but no deterioration in liver function was identified. There was no statistically significant difference in the treatment efficacy between the two groups. The hospital stay, total cost, and daily cost were lower in patients treated with ¹³¹I alone than in those treated with ¹³¹I and an ALSS (p<0.05).

CONCLUSION

The key point of treating GD patients with severe LD is to control the GD.¹³¹I is recommended as an effective and safe and should be applied as soon as possible once the diagnosis is clarified; however, when used in combination with an ALSS, there was no substantial improvement in therapeutic efficacy.

Cancer incidence and mortality following treatment of hyperthyroidism with radioactive iodine

PURPOSE OF REVIEW

Hyperthyroidism is a commonly encountered clinical issue. Radioactive iodine is one of the treatment modalities employed over the last 80 years. Prior studies are conflicting as to whether radioactive iodine is associated with an increased risk of subsequent malignancy and associated mortality. The present article reviews recent publications on this subject.

RECENT FINDINGS

Two recent studies make meaningful contributions to the existing literature; however, data remain inconsistent. The first, conducted using the Clalit Health Services database, evaluated solid tumor incidence after radioactive iodine and found no association with increased risk of solid tumor malignancy. The second, which is an updated analysis of the Cooperative Thyrotoxicosis Therapy Follow-up Study, concluded that there is a dose-dependent increased risk of solid tumor mortality using a novel method of estimating organ-specific radiation exposure.

SUMMARY

In patients with hyperthyroidism, radioactive iodine is a popular and effective treatment option. Prior studies reach conflicting conclusions on the potential relationship between radioactive iodine and both subsequent cancer incidence and mortality. We review recent publications that add to our understanding of this important clinical question.

INVESTIGATION OF THE INFLUENCE OF THYROID LOCATION ON IODINE-131 S VALUES

The use of iodine-131 S values based on reference computational phantoms with fixed thyroid model may lead to significant dosimetric errors in patients who may have different thyroid location from the reference phantoms. In the present study, we investigated individual thyroid location variation by examining the computed tomography image sets of 40 adult male and female patients. Subsequently, the thyroid location of the adult male and female mesh-type reference phantoms of the International Commission on Radiological Protection (ICRP) was adjusted to match each the highest, mean and the lowest locations of the thyroid observed in this dataset. The thyroid-adjusted phantoms were implemented into the Geant4 Monte Carlo code to calculate thyroid location-dependent iodine-131 S values (rT ← thyroid) for a total of 30 target regions. The maximum variation among the observed thyroid locations was 39 mm and 36 mm for male and female patients, respectively. The mean thyroid locations of both male and female patients showed a good agreement with the ICRP reference phantoms. The thyroid location-dependent Iodine-131 S values were significantly different from the reference phantoms for most target regions by up to a factor of 3. The use of thyroid location-dependent S values in dose reconstructions should help quantify the dosimetric uncertainty in epidemiologic investigations of patients receiving iodine-131 therapy for hyperthyroidism and thyroid cancer.

Association of ionizing radiation dose from common medical diagnostic procedures and lymphoma risk in the Epilymph case-control study

Medical diagnostic X-rays are an important source of ionizing radiation (IR) exposure in the general population; however, it is unclear if the resulting low patient doses increase lymphoma risk. We examined the association between lifetime medical diagnostic X-ray dose and lymphoma risk, taking into account potential confounding factors, including medical history. The international Epilymph study (conducted in the Czech-Republic, France, Germany, Ireland, Italy, and Spain) collected self-reported information on common diagnostic X-ray procedures from 2,362 lymphoma cases and 2,465 frequency-matched (age, sex, country) controls. Individual lifetime cumulative bone marrow (BM) dose was estimated using time period-based dose estimates for different procedures and body parts. The association between categories of BM dose and lymphoma risk was examined using unconditional logistic regression models adjusting for matching factors, socioeconomic variables, and the presence of underlying medical conditions (atopic, autoimmune, infectious diseases, osteoarthritis, having had a sick childhood, and family history of lymphoma) as potential confounders of the association. Cumulative BM dose was low (median 2.25 mGy) and was not positively associated with lymphoma risk. Odds ratios (ORs) were consistently less than 1.0 in all dose categories compared to the reference category (less than 1 mGy). Results were similar after adjustment for potential confounding factors, when using different exposure scenarios, and in analyses by lymphoma subtype and by type of control (hospital-, population-based). Overall no increased risk of lymphoma was observed. The reduced ORs may be related to unmeasured confounding or other sources of systematic bias.We found little evidence that chronic medical conditions confound lymphoma risk and medical radiation associations.

Association of Radioactive Iodine, Antithyroid Drug, and Surgical Treatments With Solid Cancer Mortality in Patients With Hyperthyroidism

IMPORTANCE

The long-term health effects of radioactive iodine (RAI) and antithyroid drug (ATD) treatments compared with surgery for hyperthyroidism remain uncertain.

OBJECTIVE

To compare solid cancer mortality rates associated with RAI and ATD treatments vs surgical management for hyperthyroidism.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study assessed patients treated for hyperthyroidism from January 1, 1946, to December 31, 1964, with follow-up through December 31, 2014. Data analysis was performed from August 1, 2019, to April 23, 2020.

EXPOSURES

Management with RAI, ATDs, surgical intervention, or combinations of these treatments.

MAIN OUTCOMES AND MEASURES

Comparisons of solid cancer mortality rates in each treatment group with expected rates from the general population were assessed using standardized mortality ratios (SMRs), and internal comparisons were assessed using hazard ratios (HRs) adjusted for age, sex, and underlying diagnosis (Graves disease or toxic nodular goiter).

RESULTS

Of 31 363 patients (24 894 [79.4%] female; mean [SD] age, 46.9 [14.8] years) included in the study, 28 523 (90.9%) had Graves disease. The median follow-up time was 26.0 years (interquartile range, 12.3-41.9 years). Important differences in patient characteristics existed across treatment groups at study entry. Notably, the drug-only group (3.6% of the cohort) included a higher proportion of patients with prior cancers (7.3% vs 1.9%-4.0%), contributing to an elevated SMR for solid cancer mortality. After excluding prior cancers, solid cancer SMRs were not elevated in any of the treatment groups (SMR for surgery only, 0.82 [95% CI, 0.66-1.00]; SMR for drugs only, 0.90 [95% CI, 0.74-1.09]; SMR for drugs and surgery, 0.88 [95% CI, 0.84-0.94]; SMR for RAI only, 0.90 [95% CI, 0.84-0.96]; SMR for surgery and RAI, 0.66 [95% CI, 0.52-0.85]; SMR for drugs and RAI, 0.94 [95% CI, 0.89-1.00]; and SMR for drugs, surgery, and RAI, 0.85 [95% CI, 0.75-0.96]), and no significant HRs for solid cancer death were observed across treatment groups. Among RAI-treated patients, HRs for solid cancer mortality increased significantly across levels of total administered activity (1.08 per 370 MBq; 95% CI, 1.03-1.13 per 370 MBq); this association was stronger among patients treated with only RAI (HR, 1.19 per 370 MBq; 95% CI, 1.09-1.30 per 370 MBq).

CONCLUSIONS AND RELEVANCE

After controlling for known sources of confounding, the study found no significant differences in the risk of solid cancer mortality by treatment group. However, among RAI-treated patients, a modest positive association was observed between total administered activity and solid cancer mortality, providing further evidence in support of a dose-dependent association between RAI and solid cancer mortality.

Association of Radioactive Iodine Treatment With Cancer Mortality in Patients With Hyperthyroidism

IMPORTANCE

Radioactive iodine (RAI) has been used extensively to treat hyperthyroidism since the 1940s. Although widely considered a safe and effective therapy, RAI has been associated with elevated risks of total and site-specific cancer death among patients with hyperthyroidism.

OBJECTIVE

To determine whether greater organ- or tissue-absorbed doses from RAI treatment are associated with overall and site-specific cancer mortality in patients with hyperthyroidism.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study is a 24-year extension of the multicenter Cooperative Thyrotoxicosis Therapy Follow-up Study, which has followed up US and UK patients diagnosed and treated for hyperthyroidism for nearly 7 decades, beginning in 1946. Patients were traced using records from the National Death Index, Social Security Administration, and other resources. After exclusions, 18 805 patients who were treated with RAI and had no history of cancer at the time of the first treatment were eligible for the current analysis. Excess relative risks (ERRs) per 100-mGy dose to the organ or tissue were calculated using multivariable-adjusted linear dose-response models and were converted to relative risks (RR = 1 + ERR). The current analyses were conducted from April 28, 2017, to January 30, 2019.

EXPOSURES

Mean total administered activity of sodium iodide I 131 was 375 MBq for patients with Graves disease and 653 MBq for patients with toxic nodular goiter. Mean organ or tissue dose estimates ranged from 20 to 99 mGy (colon or rectum, ovary, uterus, prostate, bladder, and brain/central nervous system), to 100 to 400 mGy (pancreas, kidney, liver, stomach, female breast, lung, oral mucosa, and marrow), to 1.6 Gy (esophagus), and to 130 Gy (thyroid gland).

MAIN OUTCOMES AND MEASURES

Site-specific and all solid-cancer mortality.

RESULTS

A total of 18 805 patients were included in the study cohort, and the mean (SD) entry age was 49 (14) years. Most patients were women (14 671 [78.0%]), and most had a Graves disease diagnosis (17 615 [93.7%]). Statistically significant positive associations were observed for all solid cancer mortality (n = 1984; RR at 100-mGy dose to the stomach = 1.06; 95% CI, 1.02-1.10; P = .002), including female breast cancer (n = 291; RR at 100-mGy dose to the breast = 1.12; 95% CI, 1.003-1.32; P = .04) and all other solid cancers combined (n = 1693; RR at 100-mGy dose to the stomach = 1.05; 95% CI, 1.01-1.10; P = .01). The 100-mGy dose to the stomach and breast corresponded to a mean (SD) administered activity of 243 (35) MBq and 266 (58) MBq in patients with Graves disease. For every 1000 patients with hyperthyroidism receiving typical doses to the stomach (150 to 250 mGy), an estimated lifetime excess of 19 (95% CI, 3-40) to 32 (95% CI, 5-66) solid cancer deaths could occur.

CONCLUSIONS AND RELEVANCE

In RAI-treated patients with hyperthyroidism, greater organ-absorbed doses appeared to be modestly positively associated with risk of death from solid cancer, including breast cancer. Additional studies are needed of the risks and advantages of all major treatment options available to patients with hyperthyroidism.

COMBINATION OF MOLECULAR ADSORBENT RECIRCULATING SYSTEM AND RADIOIODINE FOR THE TREATMENT OF CONCURRENT HYPERTHYROIDISM AND SEVERE LIVER DYSFUNCTION: A RETROSPECTIVE COHORT STUDY

OBJECTIVE

The treatment of hyperthyroidism associated with severe liver dysfunction (LD) is a clinical challenge, and there has been no unified examination of this problem. The objective of this study was to assess the efficacy and safety of radioiodine (¹³¹I) in combination with a molecular adsorbent recirculating system (MARS) for the treatment of hyperthyroidism complicated by severe liver LD.

METHODS

A total of 116 hyperthyroidism patients with concomitant LD who received MARS treatment were studied retrospectively. The patients were grouped according to whether or not they also received ¹³¹I treatment: Group 1 (59 patients) received ¹³¹I following MARS treatment, while Group 2 (57 cases) received only MARS. Clinical outcomes, including thyroid hormone levels, liver function parameters, and therapeutic efficacy were calculated.

RESULTS

The overall response rate was significantly greater in Group 1 than in Group 2 (P<.01). The clinical indicators improved significantly in both groups 3 months after treatment compared with before treatment (P<.05), but Group 1 showed a greater improvement. Compared with Group 1, patients in Group 2 had a longer stay in hospital (P<.05), and received more frequent MARS treatments (P<.05).

CONCLUSION

The combination of MARS and ¹³¹I for the treatment of hyperthyroidism complicated by severe LD was effective and safe. The use of this system could rapidly improve liver function and metabolism, allowing ¹³¹I therapy to be applied as early as possible with a shortened recovery time of liver function.

ABBREVIATIONS

ALSS = artificial liver support system ALT = alanine transaminase AST = aspartate transaminase ATD = antithyroid drugs DBil = direct bilirubin FT3 = free tri-iodothyronine FT4 = free thyroxine ¹³¹I = radioiodine INR = international normalized ratio LD = liver dysfunction MARS = molecular adsorbent recirculating system MELD = model for end-stage liver disease PT = prothrombin time TBil = total bilirubin TSH = thyroid-stimulating hormone.