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Radioiodine-associated thyroid cancers

  • International Association of Endocrine Surgeons—Manuscripts Presented at the 35th World Congress of the International Society of Surgery, Hong Kong, August 1993
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Abstract

Numerous investigations document that exposure to low dose external therapeutic radiation leads to the development of benign and malignant thyroid neoplasms. There is consideble controversy, however, concerning whether radioactive iodine (131I) causes thyroid cancer. The aim of this investigation was to examine our experience and that in the literature related to this problem. From 1982 to March 1993 seven of 373 patients (1.9%) with thyroid cancer who were treated by one surgeon had a history of treatment with radioactive iodine for Graves' disease and toxic nodular goiter. Sixty-five patients have previously been reported in the literature from 1957 to present. Our patients (five women, two men) ranged in age from 26 to 80 years (mean 57 years). The interval between the exposure to the internal radiation and development of cancer ranged from 3 to 29 years (mean 11.4 years), and the mean age at the time of 131I treatment was 45 years (18–76 years). The therapeutic dose of 131I was 5 to 100 mCi (mean 25.3 mCi) in our patients. Two of our patients received 131I twice. The age of patients reported in the literature at the time of 131I treatment ranged from 7 to 74 years (mean 48 years). The mean therapeutic dose of 131I was 20.6 mCi (1.25–180.0 mCi) and the latent period was documented for a mean 8.7 years (0.25–28.0 years) in these patients. Three of 29 patients in the literature received 131I twice. Fine-needle aspiration cytology of thyroid nodules was positive for cancer in six of our patients (86%). All patients were treated by total thyroidectomy, and three of them had a modified neck dissection. Six of our seven patients had invasive papillary thyroid carcinoma (stage III disease), and the seventh patient had extensive nodal metastasis and intrathyroidal invasion. Invasion into adjacent muscle and soft tissue were found in four patients, and two had tracheal invasion. Two patients had lymph node metastases. There were no postoperative complications. One patient (14%), however developed recurrent papillary and anaplastic thyroid cancer in his left neck and mediastinum 2 years after total thyroidectomy. He had extensive pulmonary metastases and malignant pleural effusions and died 23 days after a left modified radical neck dissection. In conclusion, radioactive iodine in doses to treat Graves' disease may increase the risk of developing thyroid cancer. These cancers are discovered at a later stage and appear to be aggressive.

Résumé

De nombreuses observations semblent démontrer que la radiothérapie externe à faible dose est capable de provoquer des tumeurs de la thyroïde, bénigne ou maligne. II est controversé, par contre, de savoir sil'iode radioactif peut en faire autant. Le but de cette étude a été d'examiner cette éventualité à travers notre expérience et la littérature. Entre Mars 1982, et Mars 1993, sept sur 373 (1.9%) patients traités pour un cancer de la thyroïde avait un antécédent de traitement radioactif pour maladie de Basedow ou goitre multinodulaire toxique. Soixante cinq cas ont déjà été raportés dans la littérature entre 1957 et actuellement. Notre série comporte 5 femmes et 2 hommes d'âge moyen de 57 ans (extrêmes 26 à 80). Les limites de l'intervalle entre l'exposition à l'iode et le développement du cancer ont été de 3 à 29 ans (moyen = 11.4) et l'âge moyen au moment du traitement par l'iode radioactif était de 45 ans (18–76). La dose thérapeutique était de 5 à 100 mCi (moyen 25.3 mCi). Deux de nos patients ont eu deux cures d'iode radioactif. L'âge des patients dans la littérature va de 7 à 74 ans (moyen = 48 ans). La dose moyenne d'iode 131 dans la littérature a été de 20.6 mCi (1.25–1.80 mCi) et la période de latence a été d'une moyenne de 8.7 ans (extrêmes: 0.25–28). Trois des 29 patients dans la littérature ont reçu de l'iode deux fois. La ponction biopsie des nodules, effectuée à l'aiguille fine, a révélé un cancer chez six des patients (86%). Tous les patients ont été traités par une thyroïdectomie totale et trois d'entre eux ont eu un curage ganglionnaire. Six des sept patients avaient un cancer papillaire invasif (stade III) alors que le septième avait des métastases étendues. Quatre patients avaient une invasion des structures musculaires ou des tissus mous adjacents et deux avaient une invasion trachéale. Deux patients avaient des métastases lymphatiques. Il n'y a pas eu de complications postopératoires dans cette série. Un patient (14%), cependant, a récidivé (cancer papillaire et anaplastique) au niveau du cou et dans le thorax deux ans après thyroïdectomie totale. Ce patient avait des métastases pulmonaires étendues et un épanchement pleural malin et est décédé 23 jours aprés un curage cervical. En conclusion, l'iode radioactif donné pour la maladie de Basedow peut être responsable d'un cancer de la thyroïde. Ces cancers se révèlent à un stade tardif et semblent plus invasifs.

Resumen

Numerosas investigaciones documentan el hecho de que la exposición a irradiación externa de baja dosis da lugar al desarrollo de neoplasmas tiroideos benignos y malignos. Sin embargo, existe considerable controversia en relación a si el vodo radioactivo (131-I) causa cáncer tiroideo. El propósito de la presente investigación fue examinar nuestra experiencia y la reportada en la literatura en relación a este problema. Entre 1982 y marzo de 1993, siete de 373 (1.9%) pacientes con cáncer tiroideo manejados por un cirujano tenían historia de tratamiento previo con yodo radioactivo por enfermedad de Graves y bocio nodular tóxico. Sesenta y cinco pacientes habían sido informados en la literatura previa desde 1957 hasta el presente. Nuestros pacientes (5 mujeres, 2 hombres) oscilaron en edad entre los 26 y los 80 años (media 57). El intervalo entre la exposición a la radiación interna y el desarrollo del cáncer varió entre 3 y 29 años (media 11.4) y la edad media en el momento del tratamiento con 131-I fue de 45 años (18–76). La dosis terapéutica de 131-I fue 5–100 mCi (media 25.3 mCi), y dos pacientes recibieron 131-I en dos ocasiones.

La edad de los pacientes informados en la literatura, en el momento del tratamiento con 131-I varió entre 7 y 74 años (media 48). La dosis terapéutica media de 131-I fue 20.6 mCi (1.25–180 mCi) y el período de latencia fue documentado en un valor medio de 8.7 años (0.25–28 años) en estos pacientes. Tres de 29 pacientes informados en la literatura recibieron el 131-I en dos ocasiones.

La citología por aspiracón con aguja fina de los nódulos tiroideos fue positiva para cáncer en seis de nuestros pacientes (86%).

Todos los pacientes fueron tratados con tiroidectomía total y 3 de ellos tuvieron una resección radical modificada del cuello. Seis de nuestros siete pacientes presentaban carcinoma papilar invasivo (estado III) y el séptimo exhibía extensas metástasis ganglionares e invasión intratiroidea. Se halló invasión a la musculatura adyacente y a los tejidos blandos en cuatro pacientes, y dos tenían invasión traqueal.

Dos pacientes presentaban metástasis ganglionares. No se registraron complicaciones postoperatorias. Sin embargo, un paciente (14%) desarrolló carcinoma papilar recidivante y carcinoma anaplásico en la región cervical izquierda y en el mediastino dos años luego de la tiroidectomía total; tenía extensas metástasis pulmonares y efusiones pleurales malignas y murió 23 días después de una disección radical modificada del cuello.

En conclusión, el yodo radioactivo en las dosis que se utilizan para el tratamiento de la enfermedad de Graves puede aumentar el riesgo de desarrollar cáncer tiroideo. Tales cánceres son descubiertos en etapas ulteriores y parecen ser de mayor agresividad.

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Authors and Affiliations

  1. Surgical Service, University of California-San Francisco/Mount Zion Medical Center, 1600 Divisadero Street, 94115, San Francisco, California, USA

    Richard F. Grossman M.D. & Allan E. Siperstein M.D.

  2. Department of Surgery, University of California-San Francisco, 1600 Divisadero Street, 94115, San Francisco, California, USA

    Serdar Tezelman M.D.

  3. Department of Surgery, Istanbul Faculty of Medicine, Istanbul, Turkey

    Orlo H. Clark M.D.

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  1. Serdar Tezelman M.D.
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Tezelman, S., Grossman, R.F., Siperstein, A.E. et al. Radioiodine-associated thyroid cancers. World J. Surg. 18, 522–528 (1994). https://doi.org/10.1007/BF00353754

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