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Little MP, Bazyka D, de Gonzalez AB, Brenner AV, Chumak VV, Cullings HM, Daniels RD, French B, Grant E, Hamada N, Hauptmann M, Kendall GM, Laurier D, Lee C, Lee WJ, Linet MS, Mabuchi K, Morton LM, Muirhead CR, Preston DL, Rajaraman P, Richardson DB, Sakata R, Samet JM, Simon SL, Sugiyama H, Wakeford R, Zablotska LB. A Historical Survey of Key Epidemiological Studies of Ionizing Radiation Exposure. Radiat Res 2024; 202:432-487. [PMID: 39021204 PMCID: PMC11316622 DOI: 10.1667/rade-24-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/23/2024] [Indexed: 07/20/2024]
Abstract
In this article we review the history of key epidemiological studies of populations exposed to ionizing radiation. We highlight historical and recent findings regarding radiation-associated risks for incidence and mortality of cancer and non-cancer outcomes with emphasis on study design and methods of exposure assessment and dose estimation along with brief consideration of sources of bias for a few of the more important studies. We examine the findings from the epidemiological studies of the Japanese atomic bomb survivors, persons exposed to radiation for diagnostic or therapeutic purposes, those exposed to environmental sources including Chornobyl and other reactor accidents, and occupationally exposed cohorts. We also summarize results of pooled studies. These summaries are necessarily brief, but we provide references to more detailed information. We discuss possible future directions of study, to include assessment of susceptible populations, and possible new populations, data sources, study designs and methods of analysis.
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Affiliation(s)
- Mark P. Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
- Faculty of Health and Life Sciences, Oxford Brookes University, Headington Campus, Oxford, OX3 0BP, UK
| | - Dimitry Bazyka
- National Research Center for Radiation Medicine, Hematology and Oncology, 53 Melnikov Street, Kyiv 04050, Ukraine
| | | | - Alina V. Brenner
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Vadim V. Chumak
- National Research Center for Radiation Medicine, Hematology and Oncology, 53 Melnikov Street, Kyiv 04050, Ukraine
| | - Harry M. Cullings
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Robert D. Daniels
- National Institute for Occupational Safety and Health, Cincinnati, OH, USA
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Grant
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Nobuyuki Hamada
- Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), 1646 Abiko, Chiba 270-1194, Japan
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
| | - Gerald M. Kendall
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Dominique Laurier
- Institute for Radiological Protection and Nuclear Safety, Fontenay aux Roses France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Won Jin Lee
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Martha S. Linet
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Kiyohiko Mabuchi
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Lindsay M. Morton
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | | | | | - Preetha Rajaraman
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - David B. Richardson
- Environmental and Occupational Health, 653 East Peltason, University California, Irvine, Irvine, CA 92697-3957 USA
| | - Ritsu Sakata
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Jonathan M. Samet
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Steven L. Simon
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Hiromi Sugiyama
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Lydia B. Zablotska
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, 550 16 Street, 2 floor, San Francisco, CA 94143, USA
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Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:482-490. [PMID: 38843852 PMCID: PMC11261431 DOI: 10.1016/s2352-4642(24)00104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/07/2024] [Accepted: 04/09/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Cervical spine injuries in children are uncommon but potentially devastating; however, indiscriminate neck imaging after trauma unnecessarily exposes children to ionising radiation. The aim of this study was to derive and validate a paediatric clinical prediction rule that can be incorporated into an algorithm to guide radiographic screening for cervical spine injury among children in the emergency department. METHODS In this prospective observational cohort study, we screened children aged 0-17 years presenting with known or suspected blunt trauma at 18 specialised children's emergency departments in hospitals in the USA affiliated with the Pediatric Emergency Care Applied Research Network (PECARN). Injured children were eligible for enrolment into derivation or validation cohorts by fulfilling one of the following criteria: transported from the scene of injury to the emergency department by emergency medical services; evaluated by a trauma team; and undergone neck imaging for concern for cervical spine injury either at or before arriving at the PECARN-affiliated emergency department. Children presenting with solely penetrating trauma were excluded. Before viewing an enrolled child's neck imaging results, the attending emergency department clinician completed a clinical examination and prospectively documented cervical spine injury risk factors in an electronic questionnaire. Cervical spine injuries were determined by imaging reports and telephone follow-up with guardians within 21-28 days of the emergency room encounter, and cervical spine injury was confirmed by a paediatric neurosurgeon. Factors associated with a high risk of cervical spine injury (>10%) were identified by bivariable Poisson regression with robust error estimates, and factors associated with non-negligible risk were identified by classification and regression tree (CART) analysis. Variables were combined in the cervical spine injury prediction rule. The primary outcome of interest was cervical spine injury within 28 days of initial trauma warranting inpatient observation or surgical intervention. Rule performance measures were calculated for both derivation and validation cohorts. A clinical care algorithm for determining which risk factors warrant radiographic screening for cervical spine injury after blunt trauma was applied to the study population to estimate the potential effect on reducing CT and x-ray use in the paediatric emergency department. This study is registered with ClinicalTrials.gov, NCT05049330. FINDINGS Nine emergency departments participated in the derivation cohort, and nine participated in the validation cohort. In total, 22 430 children presenting with known or suspected blunt trauma were enrolled (11 857 children in the derivation cohort; 10 573 in the validation cohort). 433 (1·9%) of the total population had confirmed cervical spine injuries. The following factors were associated with a high risk of cervical spine injury: altered mental status (Glasgow Coma Scale [GCS] score of 3-8 or unresponsive on the Alert, Verbal, Pain, Unresponsive scale [AVPU] of consciousness); abnormal airway, breathing, or circulation findings; and focal neurological deficits including paresthesia, numbness, or weakness. Of 928 in the derivation cohort presenting with at least one of these risk factors, 118 (12·7%) had cervical spine injury (risk ratio 8·9 [95% CI 7·1-11·2]). The following factors were associated with non-negligible risk of cervical spine injury by CART analysis: neck pain; altered mental status (GCS score of 9-14; verbal or pain on the AVPU; or other signs of altered mental status); substantial head injury; substantial torso injury; and midline neck tenderness. The high-risk and CART-derived factors combined and applied to the validation cohort performed with 94·3% (95% CI 90·7-97·9) sensitivity, 60·4% (59·4-61·3) specificity, and 99·9% (99·8-100·0) negative predictive value. Had the algorithm been applied to all participants to guide the use of imaging, we estimated the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%) of 22 430 children without increasing the number of children getting plain x-rays. INTERPRETATION Incorporated into a clinical algorithm, the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the emergency department and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community emergency departments. FUNDING The Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration of the US Department of Health and Human Services in the Maternal and Child Health Bureau under the Emergency Medical Services for Children programme.
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Affiliation(s)
- Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Monica Harding
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jeffrey R Leonard
- Department of Neurosurgery, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Colorado Children's Hospital, Aurora, CO, USA
| | - Fahd A Ahmad
- Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, MO, USA
| | - Lorin R Browne
- Department of Pediatrics and Department of Emergency Medicine, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Rebecca K Burger
- Department of Pediatrics, Division of Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Daniel J Corwin
- Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicolaus W Glomb
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - Lois K Lee
- Division of Emergency Medicine, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Sylvia Owusu-Ansah
- Division of Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lauren C Riney
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexander J Rogers
- Department of Emergency Medicine and Department of Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, MI, USA
| | - Daniel M Rubalcava
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Matthew A Szadkowski
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - Caleb E Ward
- Division of Emergency Medicine, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Children's National Hospital, Washington, DC, USA
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Health Dallas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA
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Stokkevåg CH, Journy N, Vogelius IR, Howell RM, Hodgson D, Bentzen SM. Radiation Therapy Technology Advances and Mitigation of Subsequent Neoplasms in Childhood Cancer Survivors. Int J Radiat Oncol Biol Phys 2024; 119:681-696. [PMID: 38430101 DOI: 10.1016/j.ijrobp.2024.01.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/17/2023] [Accepted: 01/13/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE In this Pediatric Normal Tissue Effects in the Clinic (PENTEC) vision paper, challenges and opportunities in the assessment of subsequent neoplasms (SNs) from radiation therapy (RT) are presented and discussed in the context of technology advancement. METHODS AND MATERIALS The paper discusses the current knowledge of SN risks associated with historic, contemporary, and future RT technologies. Opportunities for research and SN mitigation strategies in pediatric patients with cancer are reviewed. RESULTS Present experience with radiation carcinogenesis is from populations exposed during widely different scenarios. Knowledge gaps exist within clinical cohorts and follow-up; dose-response and volume effects; dose-rate and fractionation effects; radiation quality and proton/particle therapy; age considerations; susceptibility of specific tissues; and risks related to genetic predisposition. The biological mechanisms associated with local and patient-level risks are largely unknown. CONCLUSIONS Future cancer care is expected to involve several available RT technologies, necessitating evidence and strategies to assess the performance of competing treatments. It is essential to maximize the utilization of existing follow-up while planning for prospective data collection, including standardized registration of individual treatment information with linkage across patient databases.
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Affiliation(s)
- Camilla H Stokkevåg
- Department of Oncology and Medical Physics, Haukeland University Hospital, Bergen, Norway; Department of Physics and Technology, University of Bergen, Bergen, Norway.
| | - Neige Journy
- French National Institute of Health and Medical Research (INSERM) Unit 1018, Centre for Research in Epidemiology and Population Health, Paris Saclay University, Gustave Roussy, Villejuif, France
| | - Ivan R Vogelius
- Department of Clinical Oncology, Centre for Cancer and Organ Diseases and University of Copenhagen, Copenhagen, Denmark
| | - Rebecca M Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - David Hodgson
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland
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Saenko V, Mitsutake N. Radiation-Related Thyroid Cancer. Endocr Rev 2024; 45:1-29. [PMID: 37450579 PMCID: PMC10765163 DOI: 10.1210/endrev/bnad022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/18/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
Radiation is an environmental factor that elevates the risk of developing thyroid cancer. Actual and possible scenarios of exposures to external and internal radiation are multiple and diverse. This article reviews radiation doses to the thyroid and corresponding cancer risks due to planned, existing, and emergency exposure situations, and medical, public, and occupational categories of exposures. Any exposure scenario may deliver a range of doses to the thyroid, and the risk for cancer is addressed along with modifying factors. The consequences of the Chornobyl and Fukushima nuclear power plant accidents are described, summarizing the information on thyroid cancer epidemiology, treatment, and prognosis, clinicopathological characteristics, and genetic alterations. The Chornobyl thyroid cancers have evolved in time: becoming less aggressive and driver shifting from fusions to point mutations. A comparison of thyroid cancers from the 2 areas reveals numerous differences that cumulatively suggest the low probability of the radiogenic nature of thyroid cancers in Fukushima. In view of continuing usage of different sources of radiation in various settings, the possible ways of reducing thyroid cancer risk from exposures are considered. For external exposures, reasonable measures are generally in line with the As Low As Reasonably Achievable principle, while for internal irradiation from radioactive iodine, thyroid blocking with stable iodine may be recommended in addition to other measures in case of anticipated exposures from a nuclear reactor accident. Finally, the perspectives of studies of radiation effects on the thyroid are discussed from the epidemiological, basic science, and clinical points of view.
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Affiliation(s)
- Vladimir Saenko
- Department of Radiation Molecular Epidemiology, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki 852-8523, Japan
| | - Norisato Mitsutake
- Department of Radiation Molecular Epidemiology, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki 852-8523, Japan
- Department of Radiation Medical Sciences, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki 852-8523, Japan
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Little MP, Wakeford R, Zablotska LB, Borrego D, Griffin KT, Allodji RS, de Vathaire F, Lee C, Brenner AV, Miller JS, Campbell D, Pearce MS, Sadetzki S, Doody MM, Holmberg E, Lundell M, French B, Adams MJ, Berrington de González A, Linet MS. Radiation exposure and leukaemia risk among cohorts of persons exposed to low and moderate doses of external ionising radiation in childhood. Br J Cancer 2023; 129:1152-1165. [PMID: 37596407 PMCID: PMC10539334 DOI: 10.1038/s41416-023-02387-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Many high-dose groups demonstrate increased leukaemia risks, with risk greatest following childhood exposure; risks at low/moderate doses are less clear. METHODS We conducted a pooled analysis of the major radiation-associated leukaemias (acute myeloid leukaemia (AML) with/without the inclusion of myelodysplastic syndrome (MDS), chronic myeloid leukaemia (CML), acute lymphoblastic leukaemia (ALL)) in ten childhood-exposed groups, including Japanese atomic bomb survivors, four therapeutically irradiated and five diagnostically exposed cohorts, a mixture of incidence and mortality data. Relative/absolute risk Poisson regression models were fitted. RESULTS Of 365 cases/deaths of leukaemias excluding chronic lymphocytic leukaemia, there were 272 AML/CML/ALL among 310,905 persons (7,641,362 person-years), with mean active bone marrow (ABM) dose of 0.11 Gy (range 0-5.95). We estimated significant (P < 0.005) linear excess relative risks/Gy (ERR/Gy) for: AML (n = 140) = 1.48 (95% CI 0.59-2.85), CML (n = 61) = 1.77 (95% CI 0.38-4.50), and ALL (n = 71) = 6.65 (95% CI 2.79-14.83). There is upward curvature in the dose response for ALL and AML over the full dose range, although at lower doses (<0.5 Gy) curvature for ALL is downwards. DISCUSSION We found increased ERR/Gy for all major types of radiation-associated leukaemia after childhood exposure to ABM doses that were predominantly (for 99%) <1 Gy, and consistent with our prior analysis focusing on <100 mGy.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Lydia B Zablotska
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd floor, San Francisco, CA, 94143, USA
| | - David Borrego
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Keith T Griffin
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Rodrigue S Allodji
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif, Cedex, 94805, France
| | - Florent de Vathaire
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif, Cedex, 94805, France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Alina V Brenner
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Jeremy S Miller
- Information Management Services, Silver Spring, MD, 20904, USA
| | - David Campbell
- Information Management Services, Silver Spring, MD, 20904, USA
| | - Mark S Pearce
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- NIHR Health Protection Research Unit in chemical and radiation threats and hazards, Newcastle University, Newcastle upon Tyne, UK
| | - Siegal Sadetzki
- Israel Ministry of Health, Jerusalem, Israel
- Cancer & Radiation Epidemiology Unit, Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Michele M Doody
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Erik Holmberg
- Department of Oncology, Sahlgrenska University Hospital, S-413-45, Göteborg, Sweden
| | - Marie Lundell
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, S-17176, Stockholm, Sweden
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Jacob Adams
- University of Rochester School of Medicine and Dentistry, 265 Crittenden Boulevard, CU 420644, Rochester, NY, 14642-0644, USA
| | - Amy Berrington de González
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Martha S Linet
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
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Bhalla P, Su DM, van Oers NSC. Thymus Functionality Needs More Than a Few TECs. Front Immunol 2022; 13:864777. [PMID: 35757725 PMCID: PMC9229346 DOI: 10.3389/fimmu.2022.864777] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/03/2022] [Indexed: 12/18/2022] Open
Abstract
The thymus, a primary lymphoid organ, produces the T cells of the immune system. Originating from the 3rd pharyngeal pouch during embryogenesis, this organ functions throughout life. Yet, thymopoiesis can be transiently or permanently damaged contingent on the types of systemic stresses encountered. The thymus also undergoes a functional decline during aging, resulting in a progressive reduction in naïve T cell output. This atrophy is evidenced by a deteriorating thymic microenvironment, including, but not limited, epithelial-to-mesenchymal transitions, fibrosis and adipogenesis. An exploration of cellular changes in the thymus at various stages of life, including mouse models of in-born errors of immunity and with single cell RNA sequencing, is revealing an expanding number of distinct cell types influencing thymus functions. The thymus microenvironment, established through interactions between immature and mature thymocytes with thymus epithelial cells (TEC), is well known. Less well appreciated are the contributions of neural crest cell-derived mesenchymal cells, endothelial cells, diverse hematopoietic cell populations, adipocytes, and fibroblasts in the thymic microenvironment. In the current review, we will explore the contributions of the many stromal cell types participating in the formation, expansion, and contraction of the thymus under normal and pathophysiological processes. Such information will better inform approaches for restoring thymus functionality, including thymus organoid technologies, beneficial when an individuals’ own tissue is congenitally, clinically, or accidentally rendered non-functional.
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Affiliation(s)
- Pratibha Bhalla
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Dong-Ming Su
- Department of Microbiology, Immunology & Genetics, The University of North Texas Health Sciences Center, Fort Worth, TX, United States
| | - Nicolai S C van Oers
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Microbiology, The University of Texas Southwestern Medical Center, Dallas, TX, United States.,Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, TX, United States
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Duque CS, Vélez A, Cuartas J, Jaimes F, Dueñas JP, Agudelo M, Nikiforova MN, Nikiforov YE, Condello V. Molecular profiling of papillary thyroid carcinomas in healthcare workers exposed to low dose radiation at the workplace. Endocrine 2022; 76:95-100. [PMID: 35094311 DOI: 10.1007/s12020-021-02972-y] [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] [Received: 07/22/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Exposure to ionizing radiation, especially during childhood, is a well-established risk factor for thyroid cancer. The vast majority of radiation-induced cancers are papillary carcinomas (PTCs). These tumors typically have gene fusions in contrast to point mutations prevalent in sporadic PTCs. The aim of this study was to investigate the molecular profiles of PTC patients with workplace exposure to ionizing radiation. METHODS A retrospective review of 543 patients who underwent surgery with diagnosis of PTC was performed. A cohort of nine healthcare specialists previously exposed to radiation sources during their professional practice was selected and analyzed using the ThyroSeq mutation panel for point mutations and gene fusions associated with thyroid cancer. RESULTS The molecular analysis of surgical samples of PTCs was informative and revealed genetic alterations in five patients. BRAF V600E was found in four (67%) cases whereas RET/PTC1 fusion in one (17%) and one sample (17%) was wild type for point mutations and fusions. One sample completely failed molecular analysis while two others were negative for genes fusions but failed DNA analysis; these three samples were excluded. CONCLUSIONS In this limited cohort of healthcare workers exposed to low dose of ionizing radiation at the workplace and developed PTC, the molecular profiling determined BRAF V600E point mutation as the most common event, arguing against the role of workplace radiation exposure in the etiology of these tumors.
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Affiliation(s)
- Carlos S Duque
- Department of Surgery, Pablo Tobón Uribe Hospital, Medellin, 050021, Colombia
| | - Alejandro Vélez
- Department of Surgery, Pablo Tobón Uribe Hospital, Medellin, 050021, Colombia
- Department of Pathology, Pablo Tobón Uribe Hospital, Medellin, 050021, Colombia
| | - Jorge Cuartas
- Ophthalmology Clinic San Diego, Medellin, 050021, Colombia
| | - Fabian Jaimes
- Department of Internal Medicine, University of Antioquia, Medellin, 050021, Colombia
| | - Juan Pablo Dueñas
- Department of Surgery, Pablo Tobón Uribe Hospital, Medellin, 050021, Colombia
| | | | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh, Pittsburgh, 15213, PA, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, 15213, PA, USA
| | - Vincenzo Condello
- Department of Pathology, University of Pittsburgh, Pittsburgh, 15213, PA, USA.
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Koterov AN, Ushenkova LN, Biryukov AP. Hill’s Criterion ‘Experiment’: The Counterfactual Approach in Non-Radiation and Radiation Sciences. BIOL BULL+ 2022. [DOI: 10.1134/s1062359021120062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Little MP, Wakeford R, Zablotska LB, Borrego D, Griffin KT, Allodji RS, de Vathaire F, Lee C, Brenner AV, Miller JS, Campbell D, Sadetzki S, Doody MM, Holmberg E, Lundell M, Adams MJ, French B, Linet MS, Berrington de Gonzalez A. Lymphoma and multiple myeloma in cohorts of persons exposed to ionising radiation at a young age. Leukemia 2021; 35:2906-2916. [PMID: 34050261 PMCID: PMC8484030 DOI: 10.1038/s41375-021-01284-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 02/06/2023]
Abstract
There is limited evidence that non-leukaemic lymphoid malignancies are radiogenic. As radiation-related cancer risks are generally higher after childhood exposure, we analysed pooled lymphoid neoplasm data in nine cohorts first exposed to external radiation aged <21 years using active bone marrow (ABM) and, where available, lymphoid system doses, and harmonised outcome classification. Relative and absolute risk models were fitted. Years of entry spanned 1916-1981. At the end of follow-up (mean 42.1 years) there were 593 lymphoma (422 non-Hodgkin (NHL), 107 Hodgkin (HL), 64 uncertain subtype), 66 chronic lymphocytic leukaemia (CLL) and 122 multiple myeloma (MM) deaths and incident cases among 143,136 persons, with mean ABM dose 0.14 Gy (range 0-5.95 Gy) and mean age at first exposure 6.93 years. Excess relative risk (ERR) was not significantly increased for lymphoma (ERR/Gy = -0.001; 95% CI: -0.255, 0.279), HL (ERR/Gy = -0.113; 95% CI: -0.669, 0.709), NHL + CLL (ERR/Gy = 0.099; 95% CI: -0.149, 0.433), NHL (ERR/Gy = 0.068; 95% CI: -0.253, 0.421), CLL (ERR/Gy = 0.320; 95% CI: -0.678, 1.712), or MM (ERR/Gy = 0.149; 95% CI: -0.513, 1.063) (all p-trend > 0.4). In six cohorts with estimates of lymphatic tissue dose, borderline significant increased risks (p-trend = 0.02-0.07) were observed for NHL + CLL, NHL, and CLL. Further pooled epidemiological studies are needed with longer follow-up, central outcome review by expert hematopathologists, and assessment of radiation doses to lymphoid tissues.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Institute of Population Health, The University of Manchester, Manchester, UK
| | - Lydia B Zablotska
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, CA, USA
| | - David Borrego
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Keith T Griffin
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Rodrigue S Allodji
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif Cedex, France
| | - Florent de Vathaire
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif Cedex, France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Alina V Brenner
- Radiation Effects Research Foundation, Hiroshima City, Japan
| | | | | | - Siegal Sadetzki
- Israel Ministry of Health, Jerusalem, Israel
- Cancer & Radiation Epidemiology Unit, Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Michele M Doody
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Erik Holmberg
- Department of Oncology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Marie Lundell
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Jacob Adams
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martha S Linet
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
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Crawford TO, Sumner CJ. Assuring long-term safety of highly effective gene-modulating therapeutics for rare diseases. J Clin Invest 2021; 131:e152817. [PMID: 34338226 DOI: 10.1172/jci152817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
| | - Charlotte J Sumner
- Department of Neurology.,Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
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11
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[Low-dose irradiation of non-malignant diseases: Did we throw the baby out with the bathwater?]. Cancer Radiother 2021; 25:279-282. [PMID: 33451911 DOI: 10.1016/j.canrad.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 12/25/2022]
Abstract
The irradiation of non-malignant diseases, essentially for anti-inflammatory purpose, have been largely proposed and performed worldwide until the 1970-80s. At that time, the better assessment of the radio-induced malignancies, essentially in children and young patients, as well as the efficacy of the new anti-inflammatory drugs (steroids and non-steroids), led to the almost disappearance of those techniques, at least in France. In contrast, our German colleagues are still going on treating about 50,000 patients per year for non-malignant (more or less severe) diseases. After a short historical overview, the present article suggests that we were possibly going too far in the rejection of those low-dose irradiations for benign lesions. The recent emergence of new preclinical data, the better understanding of the risk of radio-induced secondary tumours (almost nil in the elderly), and the severity of some situations, such as the cytokine storm of the COVID-19, should probably lead us to reconsider those low - and sometimes very low (less than 1Gy) - irradiations for well-selected indications in the elderly.
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12
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Howell RM, Smith SA, Weathers RE, Kry SF, Stovall M. Adaptations to a Generalized Radiation Dose Reconstruction Methodology for Use in Epidemiologic Studies: An Update from the MD Anderson Late Effect Group. Radiat Res 2019; 192:169-188. [PMID: 31211642 PMCID: PMC8041091 DOI: 10.1667/rr15201.1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Epidemiologic studies that include patients who underwent radiation therapy for the treatment of cancer aim to quantify the relationship between radiotherapy and the risk of subsequent late effects. Because of the long follow-up period required to observe late effects, these studies are conducted retrospectively. The studies routinely include patients treated across numerous institutions using a wide range of technologies and represent treatments over several decades. As a result, determining the dose throughout the patient's body is uniquely challenging. Therefore, estimating doses throughout the patient's body for epidemiologic studies requires special methodologies that are generally applied to a wide range of radiotherapy techniques. Over ten years ago, the MD Anderson Late Effects Group described various dose reconstruction methods for therapeutic and diagnostic radiation exposure for epidemiologic studies. Here we provide an update to the most widely used dose reconstruction methodology for epidemiologic studies, analytical model calculations combined with a 3D age-specific computational phantom. In particular, we describe the various adaptations (and enhancements) of that methodology, as well as how they have been used in radiation epidemiology studies and may be used in future studies.
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Affiliation(s)
- Rebecca M. Howell
- Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, Texas
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13
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Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner EB, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics 2019; 144:peds.2018-3221. [PMID: 31221898 PMCID: PMC6615532 DOI: 10.1542/peds.2018-3221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific. CONCLUSIONS Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.
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Affiliation(s)
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Hamilton Schwartz
- Department of Pediatrics, Cincinnati
Children’s Hospital Medical Center and College of Medicine, University of
Cincinnati, Cincinnati, Ohio; and
| | - Michael Wallendorf
- Biostatistics, School of Medicine, Washington
University, St Louis, Missouri
| | - Jeffrey R. Leonard
- Neurosurgery, Nationwide Children’s Hospital
and College of Medicine, The Ohio State University, Columbus, Ohio
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics,
School of Medicine, University of California, Davis, Sacramento,
California
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Liang L, Zheng XC, Hu MJ, Zhang Q, Wang SY, Huang F. Association of benign thyroid diseases with thyroid cancer risk: a meta-analysis of prospective observational studies. J Endocrinol Invest 2019; 42:673-685. [PMID: 30387079 DOI: 10.1007/s40618-018-0968-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 10/13/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Evidence showed that benign thyroid disease was one of the risk factors for thyroid cancer. However, the results of some studies were inconsistent and were previously meta-analyses of case-control studies. Therefore, we performed a meta-analysis of prospective studies to investigate the relationship between benign thyroid diseases and thyroid cancer risk. METHODS All eligible studies were identified via systematic searches of multiple literature databases. The combined RR (relative risk)/HR (hazard ratio) or SIR (standardized incidence ratio) with 95% confidence interval was calculated. Heterogeneity was assessed with the I2 test. Publication bias and subgroup analyses were also performed. RESULTS Twelve studies were eligible for inclusion in the meta-analysis. The pooled RR/HR of thyroid carcinoma in benign thyroid diseases was 4.39 (95% CI 3.22-5.55). The pooled SIR of thyroid carcinoma in benign thyroid diseases was 5.98 (95% CI 4.09-7.86). Subgroup analysis was performed using the type of benign thyroid diseases. Effect value was RR/HR: hyperthyroidism (RR/HR = 3.89, 95% CI = 1.69-6.08), hypothyroidism (RR/HR = 2.72, 95% CI = 1.04-4.41), and goiter (RR/HR = 22.18, 95% CI = 12.09-32.28). Effect value was SIR: hyperthyroidism (RR/HR = 5.96, 95% CI = 1.88-10.03), goiter (RR/HR = 7.65, 95% CI = 6.94-8.37), and thyroiditis (RR/HR = 3.25, 95% CI = 1.62-4.89). CONCLUSIONS Our study has shown that benign thyroid diseases might be associated with increased risk of thyroid cancer, especially in hyperthyroidism, hypothyroidism, and goiter. However, further investigation is needed to better understand the underlying biological mechanisms.
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Affiliation(s)
- L Liang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, China
| | - X-C Zheng
- Department of Head and Neck, Breast Surgery, Anhui Provincial Cancer Hospital (West Branch of The First Affiliated Hospital of University of Science and Technology of China), No. 107 East Huanhu Road, Shushan Districts, Hefei, 230088, Anhui, China
| | - M-J Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, China
| | - Q Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, China
| | - S-Y Wang
- Department of Head and Neck, Breast Surgery, Anhui Provincial Cancer Hospital (West Branch of The First Affiliated Hospital of University of Science and Technology of China), No. 107 East Huanhu Road, Shushan Districts, Hefei, 230088, Anhui, China.
| | - F Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, China.
- Central Laboratory of Preventive Medicine, School of Public Health, Anhui Medical University, No. 81 Meishan Road, Shushan District, Hefei, 230032, Anhui, China.
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15
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16
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Little MP, Wakeford R, Borrego D, French B, Zablotska LB, Adams MJ, Allodji R, de Vathaire F, Lee C, Brenner AV, Miller JS, Campbell D, Pearce MS, Doody MM, Holmberg E, Lundell M, Sadetzki S, Linet MS, Berrington de González A. Leukaemia and myeloid malignancy among people exposed to low doses (<100 mSv) of ionising radiation during childhood: a pooled analysis of nine historical cohort studies. LANCET HAEMATOLOGY 2018; 5:e346-e358. [PMID: 30026010 DOI: 10.1016/s2352-3026(18)30092-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Substantial evidence links exposure to moderate or high doses of ionising radiation, particularly in childhood, with increased risk of leukaemia. The association of leukaemia with exposure to low-dose (<100 mSv) radiation is less certain, although this is the dose range most relevant to the general population. We aimed to estimate the risk of leukaemia associated with low-dose radiation exposure in childhood (age <21 years). METHODS In this analysis of historical cohort studies, we pooled eligible cohorts reported up to June 30, 2014. We evaluated leukaemia and myeloid malignancy outcomes in these cohorts with the relevant International Classification of Diseases and International Classification of Diseases for Oncology definitions. The cohorts included had not been treated for malignant disease, had reported at least five cases of the relevant haematopoietic neoplasms, and estimated individual active bone marrow (ABM) doses. We restricted analysis to individuals who were younger than 21 years at first irradiation who had mean cumulative ABM doses of less than 100 mSv. Dose-response models were fitted by use of Poisson regression. The data were received in fully anonymised form by the statistical analyst. FINDINGS We identified nine eligible cohorts from Canada, France, Japan, Sweden, the UK, and the USA, including 262 573 people who had been exposed to less than 100 mSv enrolled between June 4, 1915, and Dec 31, 2004. Mean follow-up was 19·63 years (SD 17·75) and mean cumulative ABM dose was 19·6 mSv (SD 22·7). 154 myeloid malignancies were identified (which included 79 acute myeloid leukaemias, eight myelodysplastic syndromes, and 36 chronic myeloid leukaemias, in addition to other unspecified myeloid malignancies) and 40 acute lymphoblastic leukaemias, with 221 leukaemias (including otherwise unclassified leukaemias but excluding chronic lymphocytic leukaemia) identified overall. The fitted relative risks at 100 mSv were 3·09 (95% CI 1·41-5·92; ptrend=0·008) for acute myeloid leukaemia and myelodysplastic syndromes combined, 2·56 (1·09-5·06; ptrend=0·033) for acute myeloid leukaemia, and 5·66 (1·35-19·71; ptrend=0·023) for acute lymphoblastic leukaemia. There was no clear dose-response for chronic myeloid leukaemia, which had a relative risk at 100 mSv of 0·36 (0·00-2·36; ptrend=0·394). There were few indications of between-cohort heterogeneity or departure from linearity. For acute myeloid leukaemia and myelodysplastic syndromes combined and for acute lymphoblastic leukaemia, the dose-responses remained significant for doses of less than 50 mSv. Excess absolute risks at 100 mSv were in the range of 0·1-0·4 cases or deaths per 10 000 person-years. INTERPRETATION The risks of acute myeloid leukaemia and acute lymphoblastic leukaemia were significantly increased after cumulative doses of ionising radiation of less than 100 mSv in childhood or adolescence, with an excess risk also apparent for cumulative radiation doses of less than 50 mSv for some endpoints. These findings support an increased risk of leukaemia associated with low-dose exposure to radiation and imply that the current system of radiological protection is prudent and not overly protective. FUNDING National Cancer Institute Intramural Research Program, National Cancer Institute, and US National Institutes for Health.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Institute of Population Health, The University of Manchester, Manchester, UK
| | - David Borrego
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | | | - Lydia B Zablotska
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M Jacob Adams
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Rodrigue Allodji
- Centre for Research in Epidemiology and Population Health, INSERM Unit 1018, Institut Gustave Roussy, University of Paris-Saclay, Villejuif, France
| | - Florent de Vathaire
- Centre for Research in Epidemiology and Population Health, INSERM Unit 1018, Institut Gustave Roussy, University of Paris-Saclay, Villejuif, France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Alina V Brenner
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | | | | | - Mark S Pearce
- Institute of Health and Society, and National Institute for Health Research Health Protection Research Unit for Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle-upon-Tyne, UK
| | - Michele M Doody
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Erik Holmberg
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Lundell
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Siegal Sadetzki
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Gertner Institute, Tel Hashomer, Israel
| | - Martha S Linet
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
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17
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Little MP, Lim H, Friesen MC, Preston DL, Doody MM, Sigurdson AJ, Neta G, Alexander BH, Chang LA, Cahoon EK, Simon SL, Linet MS, Kitahara CM. Assessment of thyroid cancer risk associated with radiation dose from personal diagnostic examinations in a cohort study of US radiologic technologists, followed 1983-2014. BMJ Open 2018; 8:e021536. [PMID: 29764888 PMCID: PMC5961563 DOI: 10.1136/bmjopen-2018-021536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To assess whether personal medical diagnostic procedures over life, but particularly those associated with exposure in adulthood, were associated with increased thyroid cancer risk. DESIGN Participants from the US Radiologic Technologists Study, a large, prospective cohort, were followed from the date of first mailed questionnaire survey completed during 1983-1989 to the earliest date of self-reported diagnosis of thyroid cancer or of any other cancer than non-melanoma skin cancer (NMSC) in any of three subsequent questionnaires up to the last in 2012-2014. SETTING US nationwide, occupational cohort. PARTICIPANTS US radiologic technologists with exclusion of: those who reported a previous cancer apart from NMSC on the first questionnaire; those who reported a cancer with an unknown date of diagnosis on any of the questionnaires; and those who did not respond to both the first questionnaire and at least one subsequent questionnaire. PRIMARY OUTCOME MEASURE We used Cox proportional hazards models with age as timescale to compute HRs and 95% CI for thyroid cancer in relation to cumulative 5-year lagged diagnostic thyroid dose. RESULTS There were 414 self-reported thyroid cancers (n=275 papillary) in a cohort of 76 415 persons. Cumulative thyroid dose was non-significantly positively associated with total (excess relative risk/Gy=2.29 (95% CI -0.91 to 7.01, p=0.19)) and papillary thyroid cancer (excess relative risk/Gy=4.15 (95% CI -0.39, 11.27, p=0.08)) risk. These associations were not modified by age at, or time since, exposure and were independent of occupational exposure. CONCLUSION Our study provides weak evidence that thyroid dose from diagnostic radiation procedures over the whole of life, in particular associated with exposure in adulthood, influences adult thyroid cancer risk.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Hyeyeun Lim
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Melissa C Friesen
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | | | - Michele M Doody
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Alice J Sigurdson
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Gila Neta
- Division of Cancer Control and Population Sciences, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Bruce H Alexander
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Lienard A Chang
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
- Department of Radiation Safety and Imaging Physics, Houston Methodist Hospital, Houston, Texas, USA
| | - Elizabeth K Cahoon
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Steven L Simon
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Martha S Linet
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
| | - Cari M Kitahara
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, Maryland, USA
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18
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Adams MJ, Fisher SG, Lipshultz SE, Shore RE, Constine LS, Stovall M, Dozier A, Thevenet-Morrison K, Block R, Schwartz RG, Pearson TA. Risk of Coronary Events 55 Years after Thymic Irradiation in the Hempelmann Cohort. CARDIO-ONCOLOGY 2018; 4. [PMID: 30381795 PMCID: PMC6205237 DOI: 10.1186/s40959-018-0027-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Studies of cancer survivors treated with older radiotherapy (RT) techniques (pre-1990s) strongly suggest that ionizing radiation to the chest increases the risk of coronary heart disease (CHD). Our goal was to evaluate the impact of more modern cardiac shielding techniques of RT on the magnitude and timing of CHD risk by studying a cohort exposed to similar levels of cardiac irradiation years ago. Methods Between 2004 and 2008, we re-established a population-based, longitudinal cohort of 2657 subjects exposed to irradiation for an enlarged thymus during infancy between 1926 and 1957 and 4388 of their non-irradiated siblings. CHD events were assessed using a mailed survey and from causes of death listed in the National Death Index. We used Poisson regression methods to compare incidence rates by irradiation status and cardiac radiation dose. Results were adjusted for the CHD risk factors of attained-age, sex, diabetes, dyslipidemia hypertension and smoking. Results Median age at time of follow-up was 57.5 years (range 41.2–88.8 yrs) for irradiated and non-irradiated siblings. The mean estimated cardiac dose amongst the irradiated was 1.45 Gray (range 0.17–20.20 Gy), with 91% receiving < 3.00 Gy. During a combined 339,924 person-years of follow-up, 213 myocardial infarctions (MI) and 350 CHD events (MI, bypass surgery and angioplasty) occurred. After adjustment for attained age, gender, and other CHD risk factors, the rate ratio for MI incidence in the irradiated group was 0.98 (95%CI, 0.74–1.30), and for any CHD event was 1.07 (95%CI, 0.86–1.32). Higher radiation doses were not associated with more MIs or CHD events in this dose range, in either the crude or the adjusted analyses. Conclusions Radiation to the heart during childhood of < 3 Gy, the exposure in most of our cohort, does not increase the lifelong risk of CHD. Reducing cardiac radiation to this amount without increasing other cardiotoxic therapies may eliminate the increased CHD risk associated with radiotherapy for childhood cancer. By extension there is unlikely to be increased CHD risk from relatively higher dose imaging techniques, such as CT, because such techniques use much smaller radiation doses than received by our cohort.
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Affiliation(s)
- Michael Jacob Adams
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York (Retired)
| | - Susan G Fisher
- Department of Clinical Sciences, Lewis Katz School of Medicine Temple University Philadelphia PA
| | - Steven E Lipshultz
- Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, and the Karmanos Cancer Institute, Detroit Michigan
| | - Roy E Shore
- Department of Environmental Medicine, New York University School of Medicine, New York, New York
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester School of Medicine and Dentistry and the James P. Wilmot Cancer Center, Rochester, New York
| | - Marilyn Stovall
- Department of Radiation Physics, University of Texas, M.D. Anderson Cancer Center, Houston, Texas (Retired)
| | - Ann Dozier
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Kelly Thevenet-Morrison
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Robert Block
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Cardiology Division, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Thomas A Pearson
- Department of Epidemiology, Schools of Public Health and Health Professions and of Medicine, University of Florida, Gainesville, Florida
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19
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Abstract
BACKGROUND Radiation exposure is a well-known risk factor for thyroid cancer. However, the specific effects of diagnostic radiation exposure on thyroid cancer risk are controversial. The purpose of this study was to perform a systematic review and meta-analysis to assess the effects of diagnostic radiation exposure on thyroid cancer risk. METHODS The PubMed and EMBASE databases were searched to identify eligible studies. Summary odds ratio (OR) estimates and confidence intervals (CIs) were used to compute the risk of thyroid cancer using fixed- and random-effects models. Subgroup and sensitivity analyses were performed to evaluate the potential heterogeneity. RESULTS Nine studies from 12 publications were included in the meta-analysis. Overall exposure to diagnostic radiation exposure was associated with a significantly increased thyroid cancer risk (OR = 1.52 [CI 1.13-2.04]). The subgroup and sensitivity analyses revealed similar results. By type of exposure, exposure to computed tomography scans (OR = 1.46 [CI 1.27-1.68]) or dental x-rays (OR = 1.69 [CI 1.17-2.44]) were associated with an increased thyroid cancer risk. Head and neck (OR = 1.31 [CI 1.02-1.69]) and chest (OR = 1.71 [CI 1.09-2.69]) exposure to diagnostic radiation was associated with an increased thyroid cancer risk. CONCLUSIONS The results of this meta-analysis indicate that diagnostic radiation exposure is associated with an increased thyroid cancer risk. Therefore, to the extent that it will not compromise the information being sought, radiation exposure to the thyroid should be minimized during diagnostic examinations.
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Affiliation(s)
- Mi Ah Han
- 1 Department of Preventive Medicine, College of Medicine, Chosun University , Korea
| | - Jin Hwa Kim
- 2 Department of Internal Medicine, College of Medicine, Chosun University , Korea
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Bhatti S, Hendel RC, Lopez-Mattei J, Schwartz RG, Raff G, Einstein AJ. Frequent MUGA testing in a myeloma patient: A case-based ethics discussion. J Nucl Cardiol 2017; 24:1350-1354. [PMID: 27272150 DOI: 10.1007/s12350-016-0540-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/03/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Sabha Bhatti
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Robert C Hendel
- Departments of Medicine and Radiology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan Lopez-Mattei
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Division of Internal Medicine, Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester, Rochester, NY, USA
| | - Gilbert Raff
- Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI, USA
| | - Andrew J Einstein
- Department of Medicine, Division of Cardiology, Columbia University Medical Center and New York-Presbyterian Hospital, 622 West 168th Street, PH 10-203B, New York, NY, 10032, USA.
- Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, 622 West 168th Street, PH 10-203B, New York, NY, 10032, USA.
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Pan H, Gazarian A, Mollet I, Mathias V, Dubois V, Sobh M, Buff S, Dubernard JM, Michallet M, Michallet MC. Lymphodepletive effects of rabbit anti-pig thymocyte globulin in neonatal swines. Transpl Immunol 2016; 39:74-83. [DOI: 10.1016/j.trim.2016.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 12/29/2022]
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Veiga LHS, Holmberg E, Anderson H, Pottern L, Sadetzki S, Adams MJ, Sakata R, Schneider AB, Inskip P, Bhatti P, Johansson R, Neta G, Shore R, de Vathaire F, Damber L, Kleinerman R, Hawkins MM, Tucker M, Lundell M, Lubin JH. Thyroid Cancer after Childhood Exposure to External Radiation: An Updated Pooled Analysis of 12 Studies. Radiat Res 2016; 185:473-84. [PMID: 27128740 DOI: 10.1667/rr14213.1] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Studies have causally linked external thyroid radiation exposure in childhood with thyroid cancer. In 1995, investigators conducted relative risk analyses of pooled data from seven epidemiologic studies. Doses were mostly <10 Gy, although childhood cancer therapies can result in thyroid doses >50 Gy. We pooled data from 12 studies of thyroid cancer patients who were exposed to radiation in childhood (ages <20 years), more than doubling the data, including 1,070 (927 exposed) thyroid cancers and 5.3 million (3.4 million exposed) person-years. Relative risks increased supralinearly through 2-4 Gy, leveled off between 10-30 Gy and declined thereafter, remaining significantly elevated above 50 Gy. There was a significant relative risk trend for doses <0.10 Gy (P < 0.01), with no departure from linearity (P = 0.36). We observed radiogenic effects for both papillary and nonpapillary tumors. Estimates of excess relative risk per Gy (ERR/Gy) were homogeneous by sex (P = 0.35) and number of radiation treatments (P = 0.84) and increased with decreasing age at the time of exposure. The ERR/Gy estimate was significant within ten years of radiation exposure, 2.76 (95% CI, 0.94-4.98), based on 42 exposed cases, and remained elevated 50 years and more after exposure. Finally, exposure to chemotherapy was significantly associated with thyroid cancer, with results supporting a nonsynergistic (additive) association with radiation.
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Affiliation(s)
- Lene H S Veiga
- a Divisions of Cancer Epidemiology and Genetics and.,c Institute for Radiation Protection and Dosimetry, Brazilian Nuclear Energy Commission, Rio de Janeiro, Brazil
| | - Erik Holmberg
- d Department of Oncology and Radiation Physics and the Oncological Centre, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Harald Anderson
- e Department of Cancer Epidemiology, Lund University, Lund, Sweden;,f Representing the Nordic Countries Childhood Cancer Survival Group
| | - Linda Pottern
- g Captain, United States Public Health Service (retired), Bethesda, Maryland
| | - Siegal Sadetzki
- h Cancer and Radiation Epidemiology Unit, The Gertner Institute, Chaim Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Jacob Adams
- i University of Rochester School of Medicine and Dentistry, Department of Public Health Sciences, Rochester, New York
| | - Ritsu Sakata
- j Radiation Effects Research Foundation, Hiroshima, Japan (retired)
| | - Arthur B Schneider
- k University of Illinois College of Medicine, Section of Endocrinology, Diabetes and Metabolism, Chicago, Illinois
| | - Peter Inskip
- a Divisions of Cancer Epidemiology and Genetics and
| | - Parveen Bhatti
- l Program in Epidemiology, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Robert Johansson
- m Oncology, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Gila Neta
- b Cancer Control and Population Sciences, National Cancer Institute, NIH, DHHS, Bethesda, Maryland
| | - Roy Shore
- j Radiation Effects Research Foundation, Hiroshima, Japan (retired)
| | - Florent de Vathaire
- n Cancer Epidemiology Research Unit, National Institute for Health and Medical Research-Institut Gustave Roussy, Villejuif, France
| | - Lena Damber
- m Oncology, Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | | | - Michael M Hawkins
- Centre for Childhood Cancer Survivor Studies, Department of Public Health and Epidemiology, University of Birmingham, Birmingham, United Kingdom; and
| | | | - Marie Lundell
- p Department of Medical Physics, Radiumhemmet, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Jay H Lubin
- a Divisions of Cancer Epidemiology and Genetics and
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Zablotska LB, Nadyrov EA, Polyanskaya ON, McConnell RJ, O'Kane P, Lubin J, Hatch M, Little MP, Brenner AV, Veyalkin IV, Yauseyenka VV, Bouville A, Drozdovitch VV, Minenko VF, Demidchik YE, Mabuchi K, Rozhko AV. Risk of thyroid follicular adenoma among children and adolescents in Belarus exposed to iodine-131 after the Chornobyl accident. Am J Epidemiol 2015; 182:781-90. [PMID: 26443421 PMCID: PMC4751233 DOI: 10.1093/aje/kwv127] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/01/2015] [Indexed: 11/13/2022] Open
Abstract
Several studies reported an increased risk of thyroid cancer in children and adolescents exposed to radioactive iodines, chiefly iodine-131 ((131)I), after the 1986 Chornobyl (Ukrainian spelling) nuclear power plant accident. The risk of benign thyroid tumors following such radiation exposure is much less well known. We have previously reported a novel finding of significantly increased risk of thyroid follicular adenoma in a screening study of children and adolescents exposed to the Chornobyl fallout in Ukraine. To verify this finding, we analyzed baseline screening data from a cohort of 11,613 individuals aged ≤18 years at the time of the accident in Belarus (mean age at screening = 21 years). All participants had individual (131)I doses estimated from thyroid radioactivity measurements and were screened according to a standardized protocol. We found a significant linear dose response for 38 pathologically confirmed follicular adenoma cases. The excess odds ratio per gray of 2.22 (95% confidence interval: 0.41, 13.1) was similar in males and females but decreased significantly with increasing age at exposure (P < 0.01), with the highest radiation risks estimated for those exposed at <2 years of age. Follicular adenoma radiation risks were not significantly modified by most indicators of past and current iodine deficiency. The present study confirms the (131)I-associated increases in risk of follicular adenoma in the Ukrainian population and adds new evidence on the risk increasing with decreasing age at exposure.
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Affiliation(s)
- Lydia B. Zablotska
- Correspondence to Dr. Lydia B. Zablotska, Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, 3333 California Street, Suite 280, San Francisco, CA 94118-1944 (e-mail: )
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New dosimetry for childhood skin hemangioma treatments with (226)Ra needles or tubes. Radiother Oncol 2015; 116:139-42. [PMID: 26104976 DOI: 10.1016/j.radonc.2015.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Stockholm Hemangioma Cohort is important for evaluation of late effects after exposure to ionizing radiation during childhood. Dose estimates in this cohort were based on both measurements and calculations using an old treatment planning system. METHODS We compare previously published and calculated dose estimates with new ones, obtained by Monte Carlo simulations, which mimic the hemangioma treatments with (226)Ra needles and tubes. The distances between the (226)Ra sources and the thyroid and breasts, respectively, were reassessed. RESULT The Monte Carlo calculations showed significantly lower dose values than those obtained earlier. The differences depended both on the modeling of the sources and on further individualized distances from the sources. The mean value of the new calculated doses was 25% of the old breast doses and 46% of the old thyroid doses. CONCLUSION New dosimetry for hemangioma treatments gives significantly lower organ doses for the few cases receiving the highest absorbed dose values. This implies that radiation risk estimates will increase and have to be recalculated. For retrospective studies it is now possible to calculate organ doses from radium treatments using modern treatment planning systems by modeling the source geometry carefully and apply the TG-43 formalism. It is important to be aware of the large uncertainties in calculated absorbed dose values.
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25
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Genetic predisposition for nonmedullary thyroid cancer. Discov Oncol 2014; 6:13-20. [PMID: 25338077 DOI: 10.1007/s12672-014-0205-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/15/2014] [Indexed: 10/24/2022] Open
Abstract
Nonmedullary thyroid cancer (NMTC) can be sporadic or can occur as a component cancer as part of several well-described hereditary cancer syndromes. NMTC, particularly papillary thyroid cancer, also can occur by itself in families and is often termed familial NMTC or familial papillary thyroid cancer. The occurrence of NMTC in families, along with extensive population-based evidence from patients with sporadic thyroid cancer, together suggest that NMTC has a strong genetic component, only a small proportion of which has been characterized to date. Advances in genetic and genomic technology have rapidly advanced our understanding of the complex nature of NMTC susceptibility, although much remains to be explained. Herein, we describe the current state of knowledge, starting with a brief review of hereditary syndromic causes and moving on to describe recent data using modern genomic approaches to identifying genes involved in the predisposition to NMTC.
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Chirlaque MD, Moldenhauer F, Salmerón D, Navarro C. Patrón evolutivo de la incidencia de cáncer de tiroides en la Región de Murcia de 1984 a 2008. GACETA SANITARIA 2014; 28:397-400. [DOI: 10.1016/j.gaceta.2014.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/06/2014] [Accepted: 05/06/2014] [Indexed: 11/29/2022]
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Yoo SS, Jorgensen TJ, Kennedy AR, Boice JD, Shapiro A, Hu TCC, Moyer BR, Grace MB, Kelloff GJ, Fenech M, Prasanna PGS, Coleman CN. Mitigating the risk of radiation-induced cancers: limitations and paradigms in drug development. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2014; 34:R25-52. [PMID: 24727460 PMCID: PMC7668684 DOI: 10.1088/0952-4746/34/2/r25] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The United States radiation medical countermeasures (MCM) programme for radiological and nuclear incidents has been focusing on developing mitigators for the acute radiation syndrome (ARS) and delayed effects of acute radiation exposure (DEARE), and biodosimetry technologies to provide radiation dose assessments for guiding treatment. Because a nuclear accident or terrorist incident could potentially expose a large number of people to low to moderate doses of ionising radiation, and thus increase their excess lifetime cancer risk, there is an interest in developing mitigators for this purpose. This article discusses the current status, issues, and challenges regarding development of mitigators against radiation-induced cancers. The challenges of developing mitigators for ARS include: the long latency between exposure and cancer manifestation, limitations of animal models, potential side effects of the mitigator itself, potential need for long-term use, the complexity of human trials to demonstrate effectiveness, and statistical power constraints for measuring health risks (and reduction of health risks after mitigation) following relatively low radiation doses (<0.75 Gy). Nevertheless, progress in the understanding of the molecular mechanisms resulting in radiation injury, along with parallel progress in dose assessment technologies, make this an opportune, if not critical, time to invest in research strategies that result in the development of agents to lower the risk of radiation-induced cancers for populations that survive a significant radiation exposure incident.
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Affiliation(s)
- Stephen S Yoo
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- SSY, PGSP and CNC had equal contribution in the preparation of this manuscript
| | - Timothy J Jorgensen
- Department of Radiation Medicine, Georgetown University School of Medicine, Washington DC, USA
| | - Ann R Kennedy
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Boice
- Department of Medicine, Division of Epidemiology, Vanderbilt-Ingram Cancer Center, Vanderbilt School of Medicine, Nashville, TN, USA
- National Council on Radiation Protection and Measurements, Bethesda, MD, USA
| | - Alla Shapiro
- Office of Counter-Terrorism and Emergency Coordination, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | - Tom C-C Hu
- Division of CBRN Countermeasures, Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, Washington, DC, USA
| | - Brian R Moyer
- Division of CBRN Countermeasures, Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, Washington, DC, USA
| | - Marcy B Grace
- Division of CBRN Countermeasures, Biomedical Advanced Research and Development Authority (BARDA), Office of the Assistant Secretary for Preparedness and Response, Office of the Secretary, Department of Health and Human Services, Washington, DC, USA
| | - Gary J Kelloff
- Cancer Imaging Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Michael Fenech
- Commonwealth Scientific and Industrial Research Organisation, Adelaide, Australia
| | - Pataje G S Prasanna
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- SSY, PGSP and CNC had equal contribution in the preparation of this manuscript
| | - C Norman Coleman
- Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
- SSY, PGSP and CNC had equal contribution in the preparation of this manuscript
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Szajerski P, Zaborski M, Bem H, Baryn W, Kusiak E. Optimization of the heavy metal (Bi-W-Gd-Sb) concentrations in the elastomeric shields for computer tomography (CT). J Radioanal Nucl Chem 2014; 300:385-391. [PMID: 26224969 PMCID: PMC4513903 DOI: 10.1007/s10967-014-2985-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Indexed: 11/03/2022]
Abstract
Eight elastomeric composites (NRU, GR1-GR4, NRBG08-NRBG24) containing mixtures of different proportions of heavy metal additives (Bi, W, Gd and Sb) have been synthesized and examined as protective shields. The NRU sample was a pure rubber matrix and served as a reference sample for heavy metal modified composites. Experimental procedure used for evaluation of the composite shields and their attenuation properties was based on the utilization of HPGe spectrometry and analysis of X-ray fluorescence radiation intensity of the heavy metal additives in the following energy ranges for: Sb (20-35 keV), Gd (35-55 keV), W (55-70 keV) and Bi (70-90 keV). The main contributor to the induced X-ray fluorescence radiation within the shield is Bi additive and the intensity of the X-ray radiation generated within the energy range of 70-90 keV strongly depends on its concentration. It was found that decreasing concentration of the Bi fraction from 0.35 (GR samples) to 0.15 (NRBG samples) results in significant lowering Bi X-ray fluorescence radiation within the 70-90 keV energy range. Secondary effect of decreasing Bi concentration was efficient diminishing excitation processes for lower Z heavy metal additives (W, Gd and Sb, GR vs. NRBG samples). As the final quality parameter of the shielding properties for the examined elastomers, dose reduction factor (DRF) coefficients were calculated for each shield. It was found, that the best shielding properties are observed for composites with lower Bi concentration (0.15 vs. 0.35 Bi mass fraction) with only slight further improvement of their parameters (DRF) with increasing of Gd concentration (Gd mass fraction 0.08, 0.16 and 0.24). The most efficient dose reduction composite was found to be NRBG24 elastomer with DRF value 0.47 (53 % dose reduction) for ca. 2 mm and 0.44 g/cm2 layer thickness.
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Affiliation(s)
- Piotr Szajerski
- Institute of Applied Radiation Chemistry, Lodz University of Technology, Wroblewskiego 15, 90-924 Lodz, Poland
| | - Marian Zaborski
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
| | - Henryk Bem
- Institute of Applied Radiation Chemistry, Lodz University of Technology, Wroblewskiego 15, 90-924 Lodz, Poland
| | - Wlodzimierz Baryn
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
| | - Edyta Kusiak
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
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Oh JS, Koea JB. Radiation risks associated with serial imaging in colorectal cancer patients: Should we worry? World J Gastroenterol 2014; 20:100-109. [PMID: 24415862 PMCID: PMC3885998 DOI: 10.3748/wjg.v20.i1.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/31/2013] [Accepted: 08/09/2013] [Indexed: 02/06/2023] Open
Abstract
To provide an overview of the radiation related cancer risk associated with multiple computed tomographic scans required for follow up in colorectal cancer patients. A literature search of the PubMed and Cochrane Library databases was carried out and limited to the last 10 years from December 2012. Inclusion criteria were studies where computed tomographic scans or radiation from other medical imaging modalities were used and the risks associated with ionizing radiation reported. Thirty-six studies were included for appraisal with no randomized controlled trials. Thirty-four of the thirty-six studies showed a positive association between medical imaging radiation and increased risk of cancer. The radiation dose absorbed and cancer risk was greater in children and young adults than in older patients. Most studies included in the review used a linear, no-threshold model to calculate cancer risks and this may not be applicable at low radiation doses. Many studies are retrospective and ensuring complete follow up on thousands of patients is difficult. There was a minor increased risk of cancer from ionizing radiation in medical imaging studies. The radiation risks of low dose exposure (< 50 milli-Sieverts) are uncertain. A clinically justified scan in the context of colorectal cancer is likely to provide more benefits than harm but current guidelines for patient follow up will need to be revised to accommodate a more aggressive approach to treating metastatic disease.
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Szajerski P, Zaborski M, Bem H, Baryn W, Kusiak E. Generation of the additional fluorescence radiation in the elastomeric shields used in computer tomography (CT). J Radioanal Nucl Chem 2013; 298:1913-1921. [PMID: 26224949 PMCID: PMC4514613 DOI: 10.1007/s10967-013-2556-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Indexed: 11/03/2022]
Abstract
Two commercially available (EP, Z) and eight new elastomeric composites (M1-M4, G1-G4, of thickness ≈1 mm) containing mixtures of differing proportions of heavy metal additives (Bi, W, Gd and Sb) have been synthesised and examined as protective shields. The intensity of the X-ray fluorescence radiation generated in the typical elastomeric shields for CT, containing Bi and other heavy metal additives influence on the practical shielding properties. A method for assessing the radiation shielding properties of elastomeric composites used in CT examination procedures via X-ray spectrometry has been proposed. To measure the radiation reduction ability of the protective shields, the dose reduction factor (DRF) has been determined. The lead equivalents for the examined composites were within the ranges of 0.046-0.128 and 0.048-0.130 mm for 122.1 and 136.5 keV photons, respectively. The proposed method, unlike to the common approach, includes a dose contribution from the induced X-ray fluorescence radiation of the heavy metal elements in the protective shields. The results clearly indicate that among the examined compositions, the highest values DRF have been achieved with preparations containing Bi+W, Bi+W+Gd and Bi+W+Sb mixtures with gradually decreasing content of heavy metal additives in the following order: Bi, W, Gd and Sb. The respective values of DRF obtained for the investigated composites were 21, 28 and 27 % dose reduction for a 1 mm thick shield and 39 and ~50 % for a 2 mm thick layer (M1-M4).
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Affiliation(s)
- P. Szajerski
- Institute of Applied Radiation Chemistry, Lodz University of Technology, Wroblewskiego 15, 90-924 Lodz, Poland
| | - M. Zaborski
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
| | - H. Bem
- Institute of Applied Radiation Chemistry, Lodz University of Technology, Wroblewskiego 15, 90-924 Lodz, Poland
| | - W. Baryn
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
| | - E. Kusiak
- Institute of Polymer and Dye Technology, Lodz University of Technology, Stefanowskiego 12/16, 90-924 Lodz, Poland
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Furukawa K, Preston D, Funamoto S, Yonehara S, Ito M, Tokuoka S, Sugiyama H, Soda M, Ozasa K, Mabuchi K. Long-term trend of thyroid cancer risk among Japanese atomic-bomb survivors: 60 years after exposure. Int J Cancer 2013; 132:1222-6. [PMID: 22847218 PMCID: PMC3910094 DOI: 10.1002/ijc.27749] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/09/2012] [Indexed: 11/12/2022]
Abstract
Thyroid cancer risk following exposure to ionizing radiation in childhood and adolescence is a topic of public concern. To characterize the long-term temporal trend and age-at-exposure variation in the radiation-induced risk of thyroid cancer, we analyzed thyroid cancer incidence data for the period from 1958 through 2005 among 105,401 members of the Life Span Study cohort of Japanese atomic-bomb survivors. During the follow-up period, 371 thyroid cancer cases (excluding those with microcarcinoma with a diameter <10 mm) were identified as a first primary among the eligible subjects. Using a linear dose-response model, the excess relative risk of thyroid cancer at 1 Gy of radiation exposure was estimated as 1.28 (95% confidence interval: 0.59-2.70) at age 60 after acute exposure at age 10. The risk decreased sharply with increasing age-at-exposure and there was little evidence of increased thyroid cancer rates for those exposed after age 20. About 36% of the thyroid cancer cases among those exposed before age 20 were estimated to be attributable to radiation exposure. While the magnitude of the excess risk has decreased with increasing attained age or time since exposure, the excess thyroid cancer risk associated with childhood exposure has persisted for >50 years after exposure.
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Affiliation(s)
- Kyoji Furukawa
- Radiation Effects Research Foundation, Hiroshima and Nagasaki, Japan.
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Cappa M, Cambiaso P, Genovese E, Kiepe D, Colajacomo M, Giannico S, Giannone G, Guglielmi R, Papini L, Cannatà V. No thyroid abnormalities in patients submitted to cardiac catheterization in the first eighteen months of life. J Endocrinol Invest 2013; 36:7-11. [PMID: 22189459 DOI: 10.3275/8193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND No data are available about the risk of thyroid disturbance after exposure to low-dose radiation due to the use of cardiac catheterization in the first years of life. AIM To determine the risk of functional and morphological thyroid abnormalities in a homogeneous cohort of patients who underwent diagnostic low-dose radiation for heart catheterization during the first 18 months of life. SUBJECTS AND METHODS Fifty-five patients, submitted to cardiac catheterization during the first 18 months of life, underwent evaluation of the thyroid function and structure after a median period of 13 yr since the first radiation exposure. Sixty-eight unexposed controls matched for age and sex, underwent the same protocol. Twenty-two patients were then re-evaluated after a median period of 22 yr. RESULTS Thyroid function resulted normal in both patients and controls. The prevalence of small thyroid nodules and inhomogeneous structures in ultrasound study was not augmented in irradiated patients compared to controls. No thyroid tumors or reduced thyroid volume were observed. CONCLUSIONS Neither functional nor morphological disorders of the thyroid gland were demonstrated after a period up to 24 yr in patients exposed to diagnostic ionizing radiation for cardiac catheterization during the first 18 months of life.
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Affiliation(s)
- M Cappa
- Department University-Hospital, Endocrinology Unit, Bambino Gesù Children's Hospital-Tor Vergata University, Rome, Italy.
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Kepros JP, Opreanu RC, Samaraweera R, Briningstool A, Morrison CA, Mosher BD, Schneider P, Stevens P. Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk. Eur J Trauma Emerg Surg 2012; 39:15-24. [PMID: 26814919 DOI: 10.1007/s00068-012-0201-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 06/06/2012] [Indexed: 02/06/2023]
Abstract
Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277-2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.
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Affiliation(s)
- J P Kepros
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA. .,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA.
| | - R C Opreanu
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.
| | - R Samaraweera
- Department of Radiology, Sparrow Hospital, Lansing, MI, USA
| | - A Briningstool
- Emergency Department, Sparrow Hospital, Lansing, MI, USA
| | - C A Morrison
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - B D Mosher
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - P Schneider
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - P Stevens
- Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
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Theoretical increase of thyroid cancer induction from cervical spine multidetector computed tomography in pediatric trauma patients. J Trauma Acute Care Surg 2012; 72:403-9. [PMID: 22327982 DOI: 10.1097/ta.0b013e31823a4bd7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The trend of increasing cervical spine multidirectional computed tomography (MDCT) imaging of pediatric trauma patients is characteristic of the overall dramatic increase in computed tomography utilization in the United States. The purpose of this study is to compare the amount of radiation a pediatric trauma patient absorbs to the thyroid from plain radiographs and MDCT of the cervical spine and to express risk by calculation of theoretical thyroid cancer induction. METHODS A retrospective evaluation of pediatric trauma patients admitted from October 1, 2004, to October 31, 2009, was performed at an academic, Level I trauma center. Inclusion criteria were Level I/II trauma patients, cervical spine imaging performed at our institution, and age <18 years. Absorbed thyroid radiation was calculated for patients receiving plain radiographs or MDCT. Thyroid cancer risk was calculated using the 2006 Biological Effects on Ionizing Radiation VII report. RESULTS Six hundred seventeen patients met inclusion criteria: 224 received cervical spine radiographs and 393 received cervical spine MDCT. The mean thyroid radiation absorbed from radiographs was 0.90 mGy for males and 0.96 mGy for females compared with 63.6 mGy (males) and 64.2 mGy (females) receiving MDCT (p < 0.001). The median excess relative risk of thyroid cancer induction from one cervical spine MDCT in males was 13.0% and females was 25.0%, compared with 0.24% (males) and 0.51% (females) for radiographs (p < 0.001). CONCLUSIONS The significant difference in radiation that MDCT delivers to the pediatric trauma patient when compared with plain radiographs should temper routine use of computed tomography in pediatric cervical spine clearance algorithms.
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Abstract
The chest is the most frequently evaluated region of the body in children. The majority of thoracic diagnostic imaging, namely "conventional" radiography (film screen, computed radiography and direct/digital radiography), fluoroscopy and angiography, and computed tomography, depends on ionizing radiation. Since errors, oversights, and inattention to radiation exposure continue to be extremely visible issue for radiology in the public eye it is incumbent on the imaging community to maximize the yield and minimize both the real and potential radiation risks with diagnostic imaging. Technical (e.g. equipment and technique) strategies can reduce exposure risk and improve study quality, but these must be matched with efforts to optimize appropriate utilization for safe and effective healthcare in thoracic imaging in children. To these ends, material in this chapter will review practice patterns, dose measures and modality doses, radiation biology and risks, and radiation risk reduction strategies for thoracic imaging in children.
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Affiliation(s)
- Donald P Frush
- Pediatric Radiology, Department of Radiology, 1905 Children's Health Center, Duke University Medical Center, Durham, NC 27710, USA.
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